Every finding on record at Abbey Senior Health

Based on observation, interview, and record review, the facility failed to administer insulin according to manufacturer's recommendations for one resident (Resident #3), in review of 14 sampled residents, and for two additional residents (Residents #25 and #47). The failure had the potential to result in residents not receiving their full dose of ordered insulin. The facility census was 49. Review of the undated facility policy, Insulin Administration, showed the following:-All licensed nursing staff shall administer insulin in strict accordance with a practitioner's order, state regulations, and established standards of clinical practice;-Mandatory priming protocol: For every injection using an insulin pen, the nurse must dial and prime 2 units of insulin into the needle before dialing the actual prescribed dose. The step is required for every single injection to clear air bubbles and ensure the needle is patent. 1. Review of Resident 47's Physician Order Sheet (POS), dated 06/2026, showed the following:-Insulin aspart subcutaneous (under the skin) solution pen, inject per sliding scale;-Administer insulin before meals for diabetes. Review of drugs.com for insulin aspart (fast-acting insulin), updated 03/09/26, showed before each injection, small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you receive the right dose of insulin, hold the insulin flex pen with the needle pointing up, and tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press the push button all the way in. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure. Check and make sure the dose selector is set at 0. Turn the dose selector to the number of units you need to inject. Observation on 06/09/26 at 4:00 P.M., showed Certified Medication Technician (CMT) B dialed the resident's insulin aspart flex pen to 2 units and injected the 2 units of insulin under the resident's skin. CMT B did not prime the insulin pen with 2 units of insulin prior to administering the insulin to the resident. 2. Review of Resident #3's POS, dated 06/2026, showed the following:-Insulin aspart subcutaneous solution pen injector as per sliding scale;-Administer insulin before meals for diabetes. Observation on 06/09/26 at 4:45 P.M. showed CMT B dialed the resident's insulin aspart flex pen to 2 units and injected the 2 units of insulin under the resident's skin. CMT B did not prime the insulin pen with 2 units of insulin prior to administering the insulin to the resident. During an interview on 06/09/26 at 5:00 P.M., CMT B said he/she was not aware he/she needed to prime the insulin pen before he/she administered each dose of insulin. He/She thought the insulin pen was automatically primed. 3. Review of Resident #25's POS, dated 06/2026, showed the following:-The resident had an order for insulin lispro (fast-acting insulin) pen injector, administer subcutaneously before meals for diabetes; Review of drugs.com for insulin lispro Kwik pens, dated 01/04/26, showed the following: -Select the correct dose of insulin to be administered;-Insert the needle into the skin and push the dose knob all the way in;-Continue to hold the dose knob in and slowly count to five before removing the needle. Observation on 06/10/26 at 10:35 A.M. showed the following:-CMT C primed the insulin pen with two units of insulin;-CMT C drew up the resident's ordered dose of insulin in the insulin pen and injected the needle under the skin;-CMT C immediately removed the needle from the resident's skin;-CMT C did not hold the insulin pen under the resident's skin for five seconds to ensure all the insulin was administered to the resident. During an interview on 06/10/26 at 5:35 P.M., CMT C said the following:-He/She did not know he/she should hold the needle under the skin for a certain period of time after he/she administered insulin from a pen;-He/She administered the ordered amount of insulin and then immediately removed the needle. 4. During an interview on 6/11/26 at 11:15 A.M., the Director of Nursing said she expected staff to follow the manufacturer's guidelines for administering insulin pens and the facility policy regarding insulin administration.

Based on interview and record review, the facility failed to communicate transfers and/or discharges to the State Long-Term Care Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities) for three residents (Resident #44, #70 and #34), in a review of 14 sampled residents, and for two discharged residents (Residents #4 and #38). The facility census was 49. Review of the undated facility policy, Transfer and Discharge from the Facility, showed the following:-The facility forwards a copy of all discharge notices to the Office of the State Long-Term Care Ombudsman;A. Facility staff will document in the residents' record:iv. Date copy of the notice was sent to the representative of the Office of the State Long-Term Care Ombudsman per requirements.1. Review of email communication from the State Long-Term Care Ombudsman, dated 06/05/26 at 4:14 P.M. and 06/08/26 at 11:20 A.M., showed the following:-The facility did not send a monthly log of residents transferred to the hospital for June 2025 through January 2025 to the Ombudsman program;-The Ombudsman's office stopped accepting notices of transfer and discharge in February 2026. The facility should submit the notices through the state Ombudsman's reporting platform;-She didn't see any submissions to the Ombudsman's reporting platform (February 2026 to May 2026) from the facility. 2. Review of Resident #44's face sheet showed he/she was his/her own responsible party. Review of the resident's progress note, dated 04/18/26 at 12:30 P.M., showed the resident was sent to the emergency department (ED) with complications of his/her urinary catheter (device inserted into the bladder to drain urine). Review of the resident's medical record showed no documentation staff notified the Ombudsman of the resident's transfer to the hospital on [DATE]. Review of resident's Minimum Data Set (MDS), discharge assessment, a federally mandated assessment to be completed by the facility, dated 05/12/26, showed the resident discharged to the hospital on [DATE]. Review of the resident's progress note, dated 05/06/26 at 5:00 P.M., showed the resident returned to the facility after treatment for cystitis (inflammation of the bladder). Review of the resident's medical record showed no documentation staff notified the Ombudsman of the resident's transfer to the hospital on [DATE]. 3. Review of Resident #70's progress note, dated 06/03/26 at 10:16 A.M., showed the following:-The resident complained of nausea with dry heaving;-No output in ostomy (a surgically created opening in the abdomen that allows stool or urine to exit the body when natural function is impaired) this morning;-Left lower quadrant (LLQ) distended with mild pain (normal non-distended without pain);-The resident was transferred to the hospital. Review of the resident's medical record showed no documentation facility staff notified the Ombudsman of the resident's transfer to the hospital on [DATE]. Review of the resident's progress note, dated 06/09/26 at 10:11 A.M., showed the following:-This morning at 7:30 A.M., day shift staff found the resident kneeling beside his/her bed on his/her right knee;-The resident was alert and oriented times two and slow to respond;-The resident was also weak and unsteady;-Nurse practitioner gave orders to send the resident to the hospital for further evaluation. Review of the resident's medical record showed no documentation facility staff notified the Ombudsman of the resident's transfer to the hospital on [DATE]. 4. Review of Resident #34's progress note, dated 05/17/26 at 6:13 A.M., showed the following:-Noticed dark red blood (normal no blood) in the resident's incontinence brief, looks to be from the rectum but hard to tell and has a foul odor (normal no odor);-Received a return call from the resident's physician to send the resident to the emergency room for evaluation and treatment. Review of the resident's medical record showed no documentation the facility staff notified the Ombudsman of the resident's transfer to the hospital on [DATE]. 5. Review of Resident #38's face sheet showed he/she was his/her own responsible party. Review of the resident's progress note, dated 05/24/26 at 3:50 P.M., showed the resident left the facility and said he/she would not be returning and was against medical advice (AMA). Review of the resident's medical record showed no documentation staff notified the Ombudsman when the resident discharged from the facility on 05/24/26. 6. Review of Resident #4's progress note, dated 05/15/26 at 11:11 A.M., showed the resident was discharged from the facility back to private home with home health services. Review of the resident's medical record showed no documentation facility staff notified the Ombudsman of the resident's discharge to the community on 05/15/26. 7. During an interview on 06/10/26 at 11:35 A.M., the Social Service Director (SSD) said the following:-She used to email a list of discharged residents directly to the Ombudsman, but currently didn't know who the Ombudsman was and forgot about sending the transfer/discharge list to the Ombudsman;-She had not sent a list of transfers and/or discharges to the Ombudsman's office for quite some time;-She was unaware transfer/discharge notifications were now submitted through the Ombudsman reporting platform. During an interview on 06/11/26 at 9:55 A.M., the Director of Nursing said nursing staff did not notify the Ombudsman when residents were transferred or discharged . During an interview on 06/11/26 at 10:05 A.M., the Administrator said the following:-The facility did not notify the Ombudsman of all transfers and discharges because they did not know it was required;-The facility policy said the facility would only notify the Ombudsman of immediate discharges, such as behaviors;-He was not aware of the change in the requirement to notify the Ombudsman of all transfers and discharges and the use of the Ombudsman reporting platform.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control techniques as directed in facility policy and failed to follow physician's orders to treat a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) for one resident (Resident #6), in a review of one sampled residents who had a pressure ulcer. The facility census was 49. Review of the undated facility policy, Handwashing/Hand Hygiene, showed the following:-The facility considers hand hygiene the primary means to prevent the spread of infections;-Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled;-Use an alcohol-based hand rub (ABHR) containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before handling clean or soiled dressings, gauze pads, etc.; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves. Review of the undated facility policy, Physician's Orders, showed the following:-It is the policy of the facility that all valid, authorized physician orders are implemented and followed exactly as prescribed by the attending physician or advance practice provider;-Licensed nursing staff shall ensure treatments, medications, diagnostic tests, and care directives are executed safely, accurately, and within regulatory timelines;-No prescribed order shall be altered, delayed, or omitted unless clinically contraindicated, refused by the resident, or explicitly changed by the ordering practitioner. 1. Review of Resident #6's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 04/29/26, showed the following:-Presence of a Stage 3 pressure ulcer;-Skin care/ulcer treatment included application of treatments/medications. Review of the resident's care plan, last revised 05/28/26, showed the following:-He/She had a Stage III pressure ulcer on his/her coccyx and was evaluated by the wound nurse;-On 05/13/26, there was a strong odor coming from the pressure ulcer; -Interventions included applying treatments as ordered;-The Nurse Practitioner (NP) followed the resident and monitored wound healing and made recommendations for dressing changes. Review of resident's wound assessment note, completed by the NP, dated 06/08/26, showed the following:-Chronic pressure injury to coccyx;-Culture and sensitivity (where the grown organism is exposed to various antibiotics to see which ones successfully stop the growth) were positive for klebsiella pneumoniae (a bacteria that can cause wound infections), Citrobacter Freundel complex (a group of bacteria), Enterobacter cloacae (a bacteria often found in the digestive tract;-Levaquin (an antibiotic) ordered;-Stage III wound measured 2.5 centimeters (cm) in length by 2.00 cm in width by 2.00 cm deep;-The wound had a moderate serosanguinous drainage (a normal type of wound fluid that is thin, watery, and pale pink or light red in color);-Wound was unchanged from previous assessment;-Discontinue current treatment to coccyx;-Wound care treatment to coccyx: cleanse and soak wound with a 1/4 percent (%) Dakin's (a topical antiseptic and wound cleanser) soaked gauze sponge for several minutes prior to treatment, apply gentamicin 0.1% cream (antibiotic cream) and Flagyl (antibiotic) 500 milligram (mg) tablet crushed and placed into the wound bed, pack with a strip of alginate (highly absorbent, biodegradable wound dressing), apply a small piece of xeroform gauze (a sterile, non-adhering medical dressing ) over the opening, cover with a 2 by 2 alginate, cover with a piece of ABD (thick, highly absorbent medical dressings), and secure with Tegaderm (a film dressing) on Mondays, Wednesdays, and Fridays. Observation on 06/09/26 at 4:06 P.M., showed the following:-Registered Nurse (RN) A entered the resident's room and assessed the resident's coccyx. RN A wore gloves and removed the dressing from the resident's coccyx. The Stage III pressure ulcer on the resident's coccyx had minimal drainage and no odor;-RN A removed his/her gloves, washed his/her hands, and put on gloves. RN A applied Dakins solution to gauze and wiped around the pressure ulcer;-Without changing gloves, sanitizing hands, or following the order to leave the Dakins soaked gauze in the pressure ulcer for several minutes before continuing the treatment, RN A placed gentamycin cream and crushed Flagyl inside the pressure ulcer, and cut alginate and placed it inside the pressure ulcer. RN A placed the ABD dressing over the wound, applied skin prep (a protective barrier) around the wound edges, and placed a Tegaderm dressing over the wound;-RN A did not apply xeroform gauze over the pressure ulcer opening after packing the pressure ulcer with alginate, did not cover the xeroform gauze with alginate before covering with the ABD pad and applied skin prep when it was not ordered before applying the Tegaderm. During an interview on 06/10/2026 at 3:22 P.M., RN A said he/she was not aware of the order to apply Dakins soaked gauze to the wound bed and allow it to stay in the pressure ulcer for several minutes before applying the treatment. He/She was never instructed to remove his/her gloves after cleaning a wound and before placing a new dressing on a wound. During an interview on 06/11/2026 at 9:55 A.M., the Director of Nursing (DON) said the following:-She expected staff to follow physician's orders;-She reviewed the resident's physician's orders. Staff were to soak the gauze in Dakins solution and to place the soaked gauze directly in the pressure ulcer for several minutes;-The resident had an infection in the pressure ulcer that had been difficult to treat;-It was important for staff to follow the physician's orders because not following the order did not help the resident's pressure ulcer;-She expected staff to follow appropriate hand hygiene/sanitation during the treatment which included removing gloves and sanitizing hands after cleaning the wound and before applying a clean dressing.

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, remained free from misappropriation of property. Certified Nurse Aide (CNA C) took the resident's wallet containing cash and the resident's debit card without the resident's knowledge or permission and used the debit card to pay Instant Credit Auto $450.00 (loan company for car loans), Spectrum (an internet and cable provider) $378.00 and $139.29 at Five Below (a retail store). The facility census was 53. On 9/11/25 at 12:30 P.M. the administrator was notified of the past non-compliance which occurred on 9/5/25. On 9/8/25, the administrator became aware of the violation of misappropriation of the resident's debit card and cash by CNA C when the resident logged onto his/her bank account and found the money had been withdrawn from the account. CNA C was an agency aide, and the agency was notified on 9/8/25 that the aide could not return to the facility. Staff were in-serviced on 9/8/25 of the facility policy for misappropriation and of the facility policy for locking cabinets in each resident's room. Each residents' and/or the responsible parties' preference for a locking cabinet was reviewed and revised as needed. The deficiency was corrected on 9/10/25. Review of the undated facility policy for Resident Abuse, Neglect, Misappropriation of Resident Property and Alleged Crime showed the following:-The facility affirms the right of our residents to be free from misappropriation of resident property. The facility is committed to establishing a resident sensitive and secure environment;-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Review of Resident #1's face sheet showed the following:-admitted to the facility on [DATE] with diagnoses of injury to the head and weakness.-The resident was his/her own responsible party and decision maker. During an interview on 9/11/25 at 10:25 A.M. Resident #1 said the following:-He/She admitted to the facility on [DATE] from a local hospital to have some therapy and to return home;-He/She had brought his/her wallet with $94.00 in it and debit cards and placed the wallet in the top drawer of the nightstand;-He/She did not know who came into his/her room for the first couple of days, but on 9/8/25 when he/she felt better, he/she checked his/her bank account on the computer and noticed money was used to pay a car payment, a Spectrum bill and at 5 Below;-He/She looked for his/her wallet and the wallet was gone;-He/She told a staff member; the Social Services Director and the Director of Nurses (DON) have been in to speak with him/her;-They called the police and replaced his/her wallet and the $94.00 that was in the wallet;-The police officer came and took his/her statement and a copy of the charges that were made on his/her bank account. Review of the facility staffing sheet dated 9/5/25-9/6/25 showed CNA C was assigned to provide care for the resident from 7:00 P.M. to 11:45 P.M. During an interview on 9/11/25 at 12:15 P.M. the Social Services Director (SSD) said the following:-The charge nurse reported Resident #1 said someone took his/her wallet, cash and debit cards and made charges and a purchase with the debit card;-She informed the DON, who called the police and began an investigation;-A police officer came and took some information from the resident and a copy of the resident's bank information. During an interview on 9/11/25 at 10:00 A.M. the DON said the following:-Following the report from the SSD she immediately called the police and began an investigation;-A police officer from the local police department came to the facility and was given a copy of the resident's bank account information;-The officer took this information and found that Certified Nurse Aide (CNA)C had used the resident's bank card and paid his/her car payment for $450.00, paid $383.00 to Spectrum and spent $105.00 at 5 Below;-CNA C was an aide from an agency, the facility called the agency and reported this to them and that CNA C would not be allowed to return to the facility. During an interview on 9/12/25 at 3:50 P.M. Police Officer A said the following:-He/She responded to a call from the facility on 9/8/25. The resident confirmed he/she had a missing wallet and debit card. The resident pulled up his/her bank account information on his/her computer and showed that purchases were made at Instant Credit Auto for $450.00 on 9/7/25, Spectrum for $378.00 on 9/6/25 and $139.29 at 5 Below on 9/7/25;-He/She called Spectrum and Instant Credit Auto and verified the bank account information that was used to pay those bills and the address that was on the bills matched the address used by CNA C. During an interview on 9/11/25 at 2:00 P.M. the Administrator said the following:-He would consider this misappropriation of the resident's property;-The facility replaced the resident's wallet and the cash that was in the wallet;-The resident's bank cancelled the debit card and was replacing the money that was taken;-The agency that CNA C was employed at was told of the incident and the investigation pending by the local police department;-CNA C will not be allowed to work in the facility again. #2610932

Based on interview and record review the facility failed to ensure one resident (Resident # 1 ) in a review of eleven residents was free from verbal and mental abuse when Dietary Aide E threw a ceramic dinner plate towards the resident, hitting the wall behind the resident, shattering the plate and called the resident a fucking bitch. The facility census was 50. On 12/19/24 at 11:00 A.M. the administrator was notified of the past non-compliance which occurred on 12/15/24. On 12/15/24 the administrator identified Dietary Aide E verbally and physically abused Resident #1. Upon discovery, staff suspended Dietary Aide E, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff was educated on the facility abuse and neglect policies. Dietary Aide E was terminated. The deficiency was corrected on 12/16/24. Review of the facility abuse policy, dated July 2017, showed the following: -It was the policy of the facility that all residents are to be free from abuse or neglect of a physical, emotional, verbal or sexual nature and from misappropriation of property; -Upon hiring and annually, employees will be trained on identifying resident abuse and neglect and how to go about reporting an incident; -All claims of resident neglect, abuse or misappropriation of property should be reported to the Administrator/delegate immediately; -The Administrator will promptly investigate all such claims; -The resident shall be protected throughout the investigation by removing the individual involved in the incident; -If there is evidence of any of the above, the individual involved will be immediately suspended without pay. The Administrator shall immediately notify the Department of Health and Senior Services (DHSS) and if necessary, local law enforcement. An investigation will then be conducted; -If the complaint was found to be true, the individual involved will be immediately terminated from employment; -Abuse is defined as any physical or mental injury or sexual assault inflected upon a resident other than by accidental means in a facility. Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical, mental, emotional pain or anguish; -Verbal abuse is any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability; -Physical abuse is hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment; -Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. 1. Review of Resident #1's undated Face Sheet showed diagnoses of heart failure, arthritis, pain in shoulder and knee, diseases of the respiratory system, abnormal posture, and depression. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 10/7/24, showed the following: -Cognitively intact; -No hallucinations or delusions; -No behaviors directed towards others; -Mobile with walker with staff assistance or with motorized wheelchair independently; -Required set up help with eating, transfers and personal hygiene. Review of the resident's Care Plan, revised 10/18/24, showed the following: -Required assistance with Activities of Daily Living (ADLs). Staff should allow the resident to express feelings of frustration and inadequacy, assume unhurried manner and allow ample time for tasks, encourage the resident to complete tasks as able with assist from staff only as needed to promote independence; -Alert and oriented and cognitively intact. Staff should allow the resident to make choices pertaining to care, offer reminders when meals occurred, supervise and assist with decision making as needed and talk to the resident during care and explain procedures; -Right to a dignified existence and treated with respect, dignity and freedom from abuse. Review of the resident's Nurses' Note, dated 12/15/24 at 12:03 P.M., showed the Director of Nursing (DON) documented the resident was in the dining room. Dietary staff was in the dining room and was asked by the resident not to throw away a banana peel and also some salsa. Dietary staff stated he/she needed to throw away the items or the items could cause bugs if not thrown out. The resident stated he/she did not want the items thrown out and that he/she would use those in the garden for compost. Dietary staff became angry and threw a plate at the wall causing the plate to shatter and fall to the floor. Dietary staff also went over and told the resident he/she was a fucking bitch. Review of the facility's Allegation of Abuse Summary report, dated 12/15/24, showed the following: -On 12/15/24 at approximately 9:10 A.M. dietary staff was in the dining room serving breakfast to Resident #1. Dietary Aide E went over to clear the garbage off the table which consisted of two banana peels and an individually portioned salsa container. Resident #1 requested Dietary Aide E not throw these items out so the resident could use the salsa again and the banana peels could be used in the garden compost. Dietary Aide E became upset and walked away from Resident #1 after telling the resident he/she would not be allowed to keep the banana peels. The banana peels could cause bugs in the facility and protocol stated he/she must throw the banana peels away. Dietary Aide E then stated to Resident #1 the salsa had to be thrown out because it was opened. Dietary Aide E came back out of the kitchen area and threw a plate at the wall directly behind Resident #1. Dietary Aide E went over to the resident's table and called the resident a fucking bitch and then left the floor; -On 12/16/24 Dietary Aide E was terminated. Review of Dietary Aide E's written statement, obtained by the DON, dated 12/15/24 at 11:30 A.M., showed Dietary Aide E said he/she was serving Resident #1 and was getting a little fed up, the recycling thing was getting out of hand. Resident #1 told Dietary Aide E not to throw away the salsa and Dietary Aide E got upset, and really angry and so mad that he/she threw a plate against the wall in the dining room. Dietary Aide E threw away the bananas and was upset, he/she told Resident #1 it caused flies and bugs. Dietary Aide E admitted he/she called Resident #1 a bitch. During an interview on 12/18/24 at 11:00 A.M. the DON said Registered Nurse (RN) A heard the plate hit the wall and came quickly. Two Certified Nurse Assistant (CNA) staff heard the plate hit the wall also and came to the dining room quickly. Dietary Aide E admitted he/she threw the plate and called Resident #1 a fucking bitch. During an interview on 12/18/24 at 2:17 P.M. the Human Resources Director said he/she saw the video recorded on 12/15/24 of Resident #1 in the dining room. The resident sat in a wheelchair eating. Dietary Aide E walked into view of the camera from the small kitchen area and Resident #1 sat directly in front of Dietary Aide E. Dietary Aide E picked up a ceramic plate from the serving area and threw the plate overhand, hit the wall behind the resident and the plate shattered. The video did not contain audio. The video footage was no longer available to view. During an interview on 12/19/24 at 9:01 A.M. CNA B said on 12/15/24 he/she was in the assist dining room and heard something break followed by, I can't stand you, you fucking bitch. CNA B went immediately to the main dining room and Dietary Aide E was shouting at Resident #1. The plate had shattered against the wall directly behind the resident, who sat in a wheelchair at a dining room table in the center of the room. Glass was all over the floor. Dietary Aide E had to have thrown the plate hard for it to shatter like that. The plate went directly over the resident's head. During an interview on 12/19/24 at 9:10 A.M. Registered Nurse (RN) A said on 12/15/24 at about 9:30 A.M. he/she was at the nurses' desk near the main dining room and heard a crash. RN A saw Dietary Aide E near the food serving area and he/she was angry and yelled bitch toward Resident #1 who sat in a wheelchair at the dining room table. Resident #1 was directly in front of Dietary Aide E when Dietary Aide E threw the ceramic plate over the resident's head and hit the wall behind the resident. Ceramic glass went everywhere. Dietary Aide E threw the plate hard, and it shattered and sprayed all over the dining room floor. Resident #1 said the plate flew over his/her head. RN A heard Dietary Aide E call the resident a bitch and was looking at Resident #1. Dietary Aide E abused the resident. During an interview on 12/19/24 at 9:45 A.M. CNA C said on 12/15/24 he/she was in the assist dining room and heard a crash and then heard, I hate you, you fucking bitch. CNA C went immediately to the main dining room and Dietary Aide E stood at the kitchen area and yelled at Resident #1. CNA C asked Dietary Aide E if he/she called the resident a fucking bitch and Dietary Aide E said yes. Resident #1 said Dietary Aide E threw the plate at him/her and the plate went over his/her head and missed hitting the resident. The glass plate shattered everywhere. Dietary Aide E abused the resident. During an interview on 12/18/24 at 12:25 P.M. Resident #1 said during breakfast time on 12/15/24 the resident was at the table. Dietary Aide E took his/her plate and the resident asked to keep the two banana peels for the garden compost. Dietary Aide E said no, it was rubbish and took the resident's plate. Then Dietary Aide E took the resident's small cup of salsa and was going to through it away. The resident asked Dietary Aide E to save it for the following day. Dietary Aide E said no and threw the salsa away. Resident #1 asked Dietary Aide E if he /she wanted the resident to tell his/her supervisor and Dietary Aide E then threw a plate over the resident's head and hit the wall behind the resident. The plate shattered. The plate was a ceramic dinner plate. Dietary Aide E threw the plate hard to shatter it like that. The resident did not know the plate was coming or that Dietary Aide E was angry. Dietary Aide E must have gotten angry when the resident asked if he/she should tell Dietary Aide E's supervisor about the banana peels and salsa. Resident #1 did not hear Dietary Aide E say anything. During an interview on 12/19/24 at 11:45 A.M. the Administrator said he was notified of the abuse allegation on 12/15/24. Dietary Aide E was terminated for abuse of Resident #1. Dietary Aide E's behavior was abusive. MO00246640

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to residents in a safe and sanitary manner when staff failed to employ proper hand hygiene and gloving practices and failed to store food in a manner that prevented potential contamination. Staff failed to ensure beverage and ice machines were clean and an air gap was present at ice machine drains. Staff failed to document and demonstrate knowledge of the use and testing parameters of the facility's dishwashing machines to ensure dishes were cleaned and sanitized properly. The facility census was 49. Review of the facility policy, Food and Nutrition Services Staff, revised [DATE], showed the following: -Food and nutrition services staff should wash their hands before serving food to residents; -Employees should wash their hands after collecting soiled plates and food waste and prior to handling food trays; -Bare hand contact with food is prohibited; -Gloves are worn when handling food directly and changed between tasks. Review of the undated facility policy, Procedures for Serving Food on Second and Third Floor, showed the following: -Wash your hands for 20 seconds, take paper towel, dry your hands, then turn off faucet, put on gloves; -After you finish tasks, take off gloves, wash hands, and with a new task comes new gloves; -Wash your hands before you serve food. 1. Observation on [DATE], from 4:52 P.M. to 5:05 P.M., in the third floor dining room during the dinner meal service, showed the following: -Dietary Aide I served food onto residents' plates from the steam table and counter serving area; -He/She used his/her gloved hands to grasp and move a newspaper from a resident to the nurses' station; -Without changing his/her gloves, he/she touched the inside surface of a bowl, ladeled soup into the bowl, and gave the bowl of soup to a resident; -He/She touched the handles of a resident's wheelchair, pushed the resident closer to the table, and touched the resident's arm; -He/She removed his/her gloves, did not wash his/her hands, put on new gloves, and removed soiled dishes from residents' tables to the counter; -He/She picked up a butter knife from the floor and placed it in the sink, took off one glove and put on a new glove, did not wash his/her hands, and served food onto residents' plates from the steam table; -With his/her same gloved hands, he/she turned off a faucet handle (the water was running at the sink), grabbed a piece of bread from a bag of bread, and placed the bread on a resident's plate; -He/She opened and closed the microwave door, pressed buttons on the microwave, touched resident meal cards, and continued serving residents' food during the meal service. Observation on [DATE], from 8:01 A.M. to 8:41 A.M., in the second floor dining room during the breakfast meal service, showed the following: -Dietary Aide H used his/her bare hands to pick up soiled dishes from residents' tables and placed the dishes into the sink; -Without washing his/her hands, he/she put a glove on his/her right hand, grabbed a piece of bread from a bag of bread, placed the bread in the toaster, and turned on the toaster using the toaster controls; -He/She rested his/her gloved hand on the top of the steam table, wiped his/her gloved hand on his/her apron, and grabbed another slice of bread and placed the bread in the toaster; -Without washing his/her hands or changing his/her gloves, he/she removed toast from the toaster and held the toast in his/her left bare hand while using a knife in his/her right gloved hand to spread butter on the toast; -He/She served the buttered toast to a resident, removed soiled dishes from residents' tables, poured a cup of coffee for a resident, and brought clean silverware to a resident; -He/She removed his/her glove, discarded the glove into the trash can, did not wash his/her hands, put on new gloves, and placed more bread in the toaster; -With his/her gloved hands, he/she ate food, drank from a cup, and used a napkin to wipe his/her mouth while standing at the food preparation counter; -He/She moved soiled dishes from the counter to the sink, removed his/her gloves, discarded the gloves in the trash can, and moved soiled dishes from residents' tables to the sink; -Without washing his/her hands, he/she used his/her bare hands to remove the lid of a resident's coffee mug and refill the mug with coffee; -He/She picked up soiled dishes from residents' tables and placed them on the counter by the sink; -He/She obtained a clean drinking glass, opened the refrigerator door, poured milk from a jug into the glass, and carried the glass with his/her bare hands touching the upper drinking-edge portion of the glass and gave the glass of milk to a resident. During an interview on [DATE] at 9:36 A.M., Dietary Aide D said the following: -Staff should wash their hands after performing dirty tasks, when changing gloves, and before performing clean tasks; -Staff should not eat or drink personal items in the food preparation and serving areas, such as in the second and third floor kitchenettes, and should instead consume these items in the employee breakroom; -Staff should handle dishware by the non-eating and non-drinking surfaces of those items. During an interview on [DATE] at 1:08 P.M., the Dietary Manager said the following: -She expected staff to serve, store and prepare food and beverages under safe and sanitary conditions; -Staff should wash their hands properly and change their gloves appropriately; -Staff should not handle ready-to-eat foods with their bare hands or soiled gloves; -Staff should wash their hands and change their gloves when changing tasks, after completing dirty tasks (such as picking items up from the floor) and prior to conducting clean tasks (such as serving food to residents); -Staff should not consume food or beverages in the food preparation area and should instead eat in the breakroom or dining room; -Staff should handle clean dishware by the non-eating and non-drinking sides of those items. Review of the facility policy, Food Receiving and Storage, revised [DATE], showed foods shall be received and stored in a manner that complies with safe food handling practices. 2. Observation on [DATE] at 10:55 A.M., in the kitchen dry storage room, showed the following: -The top of an open 5-pound bag of buttermilk pancake mix was loosely folded over and not securely sealed; -The dates [DATE] and [DATE] were written in marker on a zippertop bag containing approximately 10 flour tortillas. Observation on [DATE] at 9:05 A.M., in the kitchen dry storage room, showed the top of an open 5-pound bag of buttermilk pancake mix was loosely folded over and not securely sealed. Observation on [DATE] at 1:01 P.M., in the kitchen walk-in freezer, showed the following: -A bag of frozen chicken breasts was not sealed and was open to the air; -A bag of frozen chicken tenders, located in a cardboard box with flaps that were loosely closed, was not sealed and was open to the air; -A bag of frozen potatoes was not sealed and was open to the air; -A bag of frozen manicotti, located in a cardboard box with flaps that were loosely closed, was not sealed and was open to the air. During an interview on [DATE] at 1:08 P.M., the Dietary Manager said she expected staff to properly seal, label, and date food items. She expected staff to discard expired and past-dated food items. 3. Review of the ice machine vendor cleaning records showed the following: -The kitchen ice machine was cleaned, descaled, and sanitized on [DATE]; -The second floor ice machine was cleaned and sanitized on [DATE]; -The third floor ice machine was cleaned and sanitized on [DATE]; Observation on [DATE] at 4:25 P.M., in the kitchen, showed the following: -The ice machine had a heavy accumulation of white and brown crusty debris on the back side of the exterior surface; -Several dried white stains were visible across the front, back, and sides of the exterior surface; -A moderate accumulation of moist black debris was on the metal horizontal surface, located above the ice holding area, on the interior portion of the ice machine; -Approximately 0.25 inches of standing water sat in a blue plastic holder (located next to the ice machine) and a metal ice scoop sat in contact with the water. There was a moderate accumulation of dried white debris on the inside surface of the plastic scoop holder. Observation on [DATE] at 11:01 AM, in the second floor dining beverage area, showed the following: -A heavy accumulation of white and black crusty debris was visible in and around the dispensing area of the ice and water machine; -A moderate accumulation of black debris was visible between and around the nozzles of the juice dispenser; -A moderate accumulation of dark gray debris speckled the surface around the nozzles of the coffee machine. Observation on [DATE] at 7:19 AM, in the third floor dining beverage area, showed the following: -An excessive accumulation of white crusty debris and black buildup was visible in and around the dispensing area of the ice and water machine; -An excess accumulation of black debris was visible between and around the nozzles of the juice dispenser; -A moderate accumulation of dark gray debris speckled the surface around the nozzles of the coffee machine. During an interview on [DATE] at 1:08 P.M., the Dietary Supervisor said the following: -She cleaned the nozzles of the juice dispenser weekly; -She wiped the area around the spouts and primed the coffee machine on Monday ([DATE]); -When showed the photos of the machines around the nozzles and spouts, she was unaware the machines were that dirty. During an interview on [DATE] at 1:08 P.M., the Dietary Manager said the following: -A company cleaned and sanitized the ice machines about once per quarter, and dietary staff cleaned the outside of the machines monthly; -Dietary staff cleaned and sanitized the kitchen ice machine scoop weekly by running it through the dishwasher. She did not realize the kitchen ice scoop holder was holding water. 4. Observation on [DATE] at 8:37 A.M., in the third floor dining room, showed the following: -An approximate 2-foot section of 1-inch diameter PVC pipe extended from the ice machine drain into a 4-inch flanged PVC floor drain; -The 1-inch PVC pipe extended approximately 2 inches below the flood rim level of the flanged drain and contained no air gap to prevent potential backflow from the drain back into the machine. Observation on [DATE] at 8:31 A.M., in the second floor dining room, showed the following: -An approximate 2-foot section of 1-inch diameter clear hose extended from the ice machine drain into a 4-inch flanged PVC floor drain; -The clear hose extended approximately 1.5 inches below the flood rim level of the flanged drain and contained no air gap to prevent potential backflow from the drain back into the machine. During an interview on [DATE] at 1:08 P.M., the Dietary Manager said the following: -She expected there to be an adequate air gap at the ice machine drains to prevent potential backflow into the machines; -Maintenance staff were responsible for ensuring proper air gaps at the ice machine drains. During an interview on [DATE] at 2:35 P.M., the Maintenance Assistant said the following: -A company came every three to four months to clean and descale the ice machines; -He cleaned the ice machine drains monthly and as issues arose; -He checked to ensure there was an air space around the second and third floor ice machine drains that went into the flanged drains but was unaware the drains did not contain an adequate air gap (above the flood rim level of the flanged drain) to prevent potential backflow into the machines. 5. Review of the manufacturer's specification sheet for the kitchen dishmachine showed the following: -Operating temperatures: -Wash (minimum): 140 degrees Fahrenheit (F); -Sanitizing rinse (minimum): 120 degrees F; -Water flow pressure (required): ,d+[DATE] PSI (pounds per square inch); -Chemical sanitizer rinse (minimum): 50 PPM (parts per million) chlorine. Observation on [DATE] at 1:19 P.M., of the facility log Daily Temperatures for Dishwasher, located in the kitchen dishwashing room, showed the following: -Columns on the form read: Date, A.M. Test Strip, Initials, P.M. Test Strip, Initials; -A checkmark was placed in the A.M. Test Strip column for [DATE] through [DATE]; -A checkmark and/or the date was placed in the P.M. Test Strip column for [DATE] through [DATE], [DATE], [DATE], and [DATE]; -No A.M. or P.M. test strip information was logged for [DATE] or [DATE]; -No A.M. test strip information was logged for [DATE]; -No P.M. test strip information was logged for [DATE], [DATE], or [DATE]; -No chemical test strip parameters or values were written on the form; -No water temperature or water pressure parameters or values were written on the form. Observation on [DATE] from 1:13 P.M. to 1:31 P.M., in the kitchen, showed Dishwasher F operated the conveyor-style dishmachine by placing racks of soiled dishes into the entry to the machine and taking out racks of clean dishes from the exit of the machine. The following parameters were observed: -At 1:13 P.M., the rinse temperature (indicated on the machine's dial gauge) was 115 degrees F and the wash temperature was 100 degrees F; -At 1:16 P.M., the rinse temperature was 110 degrees F and the wash temperature was 100 degrees F; -At 1:19 P.M., the rinse temperature was 108 degrees F and the wash temperature was 100 degrees F; -At 1:22 P.M., the rinse temperature was 109 degrees F and the wash temperature was 100 degrees F; -At 1:26 P.M., the rinse temperature was 108 degrees F and the wash temperature was 95 degrees F. During an interview on [DATE] at 1:16 P.M., Dishwasher F said the following: -He/She didn't think the kitchen's dish machine got the dishes clean and didn't think the water in the machine got hot enough; -He/She knew he/she needed to keep the sanitizer filled for the machine but was unaware if he/she needed to monitor the water temperature or water pressure. During an interview on [DATE] at 9:41 A.M., Dishwasher Q said the following: -Staff should check the sanitizer concentration of the kitchen dishwasher at the beginning of each shift using a test strip; -The test strip should be a really dark purple (200 PPM as indicated on the test strip bottle); -The water temperature and water pressure didn't really matter for the dishwasher, it was mainly the sanitizer that was important to have at the correct level. During an interview on [DATE] at 11:45 A.M., the Dietary Supervisor said the dishwashing staff kept turning off the kitchen dishwasher and it took a long time to heat up the water again. 6. Review of the manufacturer's specification sheet for the second and third floor dishmachines showed the following: -Operating temperatures: -Wash (minimum): 120 degrees F; -Rinse (minimum): 120 degrees F; -Water flow pressure (required): ,d+[DATE] PSI; -Chemical sanitizer (minimum): 50 PPM chlorine. Review on [DATE] at 8:12 A.M., of the untitled facility log, located in the second floor kitchenette, showed the following: -Columns on the form read: Date, A.M. Test Strip 200 PPM, Initials, P.M. Test Strip 200 PPM, Initials; -A checkmark was placed in the A.M. Test Strip column for [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]; -A checkmark was placed in the P.M. Test Strip column for [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] , and [DATE]; -No A.M. or P.M. test strip information was logged for [DATE]; -No A.M. test strip information was logged for [DATE] and [DATE]; -No P.M. test strip information was logged for [DATE], [DATE] to [DATE], [DATE], and [DATE]; -No water temperature or water pressure parameters or values were written on the form. Review on [DATE] at 8:12 A.M., of the untitled facility log, located in the third floor kitchenette, showed the following: -Columns on the form read: Date, A.M. Test Strip 200 PPM, Initials, P.M. Test Strip 200 PPM, Initials; -A checkmark was placed in the A.M. Test Strip column for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]; -A checkmark was placed in the P.M. Test Strip column for [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -No A.M. or P.M. test strip information was logged for [DATE] or [DATE]; -No A.M. test strip information was logged for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -No P.M. test strip information was logged for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -No water temperature or water pressure parameters or values were written on the form. Observation on [DATE], of the second floor kitchenette dishwasher, showed the following: -At 8:44 A.M., Dietary Aide H started a load of dishes. The wash temperature (indicated on the unit's digital display) was 119 degrees F and the rinse temperature was 87 degrees F; -At 8:45 A.M., the wash temperature was 113 degrees F and the rinse temperature was 95 degrees F; -At 8:46 A.M., the cycle ended and the wash temperature was 113 degrees F and the rinse temperature was 103 degrees F; -No water pressure gauge was visible for the dishwasher. Observation on [DATE], of the third floor kitchenette dishwasher, showed the following: -At 8:22 A.M., Dietary Aide D started a load of dishes. The wash temperature was 91 degrees F and the rinse temperature was 87 degrees F; -At 8:23 A.M., the wash temperature was 91 degrees F and the rinse temperature was 102 degrees F; -At 8:24 A.M., the cycle ended and the wash temperature was 91 degrees F and the rinse temperature was 102 degrees F; -No water pressure gauge was visible for the dishwasher. During an interview on [DATE] at 8:41 A.M., Dietary Aide H said the following: -Staff washed the dishes (other than the silverware) from the second and third floor dining rooms in the in the second and third floor kitchenette dishwashers; -He/She did not monitor the water temperature or water pressure of the dishwasher located on the second floor; -He/She tested the sanitizer chemical level for the dishwasher at the end of the day. If the test strip was black, then it had enough sanitizer. If the test strip started turning white, then he/she needed to refill the sanitizer (located below the sink). During an interview on [DATE] at 9:36 A.M., Dietary Aide D said the following: -He/She turned on the dishwasher, located in the third level dining room, at the beginning of his/her shift, let it run, and then tested the sanitizer level with a chemical test strip; -The test strip should show a color that was not too light and not too dark; it should be in between the colors on the test strip bottle; -He/She was unaware of a minimum operating water temperature or water pressure the dishwasher needed to reach. During interviews on [DATE] at 11:45 A.M. and 1:08 P.M., the Dietary Supervisor said the following: -Staff should check chemical levels for the dishwashers, located in the kitchen and second and third floor kitchenettes, using chemical test strips at the beginning of each shift; -She was unaware of minimum water temperature or water pressure levels the dishwashers needed to reach. During interviews on [DATE] at 1:40 P.M. and on [DATE] at 1:08 P.M., the Dietary Manager said the following: -All of the dishwashers were low temperature machines with chemical sanitization; -The chlorine level from the sanitizer should be at least 100 parts per million; -She was unaware of a minimum water temperature or water pressure required for the dishwashers; -She expected staff to be knowledgeable on the use of and testing parameters of the dishwashers and to follow manufacturer's instructions for the machines.

Based on observation, interview and record review, the facility failed to ensure residents were aware of posted resident rights in an easily accessible area for review at their leisure. The resident census was 49. Review of the facility's policy, Resident Rights, revised February 2021 showed the following: -Federal and state laws guarantee certain basic rights to all residents of the facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Be informed about his or her rights and responsibilities; -Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter; -Copies of resident rights are posted throughout the facility. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said they did not know where the resident rights were posted in the facility. Observation on 10/23/24 at 10:45 A.M., showed the resident rights posted along the wall around the corner from the nursing station, beside a portion of the wall and near the exit door to a different part of the facility. The location of the posted resident rights was not in a frequently traveled area for a resident in a wheelchair. The location of the resident rights on the second and third floor were in the same location. During an interview on 10/25/24 at 9:11 A.M., Registered Nurse (RN) A said the following: -Resident rights should be posted for all to see; -The location of the posted resident rights was not in an area the residents would frequently go past; -The resident rights would be better if they were in a different location for the residents to see; -Prior to the state agency (SA) showing him/her where the resident rights were posted, he/she could not have told anyone where they were posted as he/she did not realize the resident rights were posted where they were. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -Resident rights should be posted for all the residents to see and review; -Resident rights are posted on the first floor by the elevator and should also be at the nursing station; -The ADON was unable to show the SA where resident rights were posted. During an interview on 10/25/24 at 12:50 P.M., the Director of Nursing (DON) said resident rights should be readily accessible for residents to see and use. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -Resident rights should be readily accessible for resident to see and use; -He felt like the location of the resident rights was in a high traffic area.

Based on observation, interview and record review, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily accessible and could be read by residents in the facility without assistance. The facility census was 49. Review of the facility's policy, Filing Grievance/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file a grievance, either orally or in writing, to the facility staff or the agency designated to hear grievances (e.g. the State Ombudsman); -A copy of the grievance/complaint procedure is posted on the resident bulleting board. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said the following: -They knew what the Ombudsman program was but was unaware of who their representative was or how to contact them; -They did not know how to contact the State Survey Agency if they had any concerns. Observation on 10/23/24 at 10:45 A.M., showed the following: -The resident rights poster was along the wall around the corner from the nursing station with the Ombudsman program number at the bottom of the poster; -The poster was located beside a portion of the wall and near the exit door to a different part of the facility; -The location of the posted Ombudsman number was not in a frequently traveled area for a resident in a wheelchair; -The posted State Survey Agency hotline number was located in a 8 x 10 inch picture frame, above the automated automatic defibrillator (AED) in an area and font type, that would be difficult for a resident to read, especially if the resident was seated in a wheelchair or had impaired vision; -The location of the Ombudsman information and State Survey Agency hotline contact information on second and third floors were in the same location. During an interview on 10/25/24 at 9:11 A.M., Registered Nurse (RN) A said the following: -Resident rights, the Ombudsman's number and state agency hotline number should be posted for all to see; -The location of the posted Ombudsman number and state agency hotline number was not in an area the residents frequently go past; -Prior to the state agency (SA) showing him/her where the Ombudsman number and state agency hotline number were posted, he/she did not realize the information was located where it was. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -The Ombudsman program number and state survey agency hotline number should be posted for all the residents to see and review; -She felt like the Ombudsman number and state agency hotline number should be posted in a higher traffic area for residents to see and where they are at could be hard for the residents to review. During an interview on 10/25/24 at 12:50 P.M., the Director of Nursing (DON) said the Ombudsman number and State Survey Agency hotline number should be readily accessible for residents to see and use. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -The Ombudsman number and State Survey Agency hotline number should be readily accessible for resident to see and use; -He felt like the location of the Ombudsman number and State Survey Agency hotline number was in a high traffic area.

Based on observation, interview, and record review, the facility failed to ensure bed rails assessments were consistent with facility policy to evaluate the resident's risk for entrapment and failed to conduct ongoing assessments to ensure the proper use and safety of the bed rails for eight residents (Residents #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include: side rails, safety rails, and grab/assist bars; -The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -The resident assessment to determine risk of entrapment includes, but is not limited to: -Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; -Size and weight; -Sleep habits; -Medication(s); -Acute medical or surgical interventions; -Underlying medical conditions; -Existence of delirium; -Ability to toilet self safely; -Cognition; -Communication; -Mobility (in and out of bed); and -Risk of falling. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Residents who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the resident's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when residents, or part of their body, are caught between rails or between the bed rails and mattress, more serious injuries from falls when residents climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the resident's physical and mental status and closely monitor high-risk patients; -A process that requires ongoing evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #12's undated Face Sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and weakness. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 03/06/24, showed the following: -Assessment did not specify if it was an admission, readmission, quarterly, annual or significant change assessment for bilateral assist bar/bed rail; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -The resident does not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? No; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? No; -Is the resident having problems with balance or poor trunk control? No; -Will/Does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has requested to have bed rails/assist bar while in bed and bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident's for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Range of motion impairment upper and lower extremity both sides; -The resident was dependent on staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on 10/23/24, showed the following: -He/She required assistance with activities of daily living (ADLs) related to mobility and impaired balance; -Assist him/her with repositioning every two hours and as needed with assistance of one to two; -Assist bars on bed are for mobility and transfer; -He/She required a mechanical lift with two staff for transfers. Review of the resident's October 2024 Physician Order Sheet (POS) showed an order for assist rail on both sides of the bed for positioning and to assist with mobility every day and night. Observation on 10/23/24 at 2:16 P.M., showed the resident lay in bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. During interview on 10/23/24 at 2:16 P.M., the resident said he/she was not able to grab the assist rail as much anymore but the assist rails made him/her feel safer when staff rolled him/her back and forth in bed. Observation on 10/24/24 at 10:38 A.M., showed staff transferred the resident from bed to his/her electric wheelchair. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. 2. Review of Resident #102's undated Face Sheet showed the following: -admitted [DATE]; -The resident was his/her own responsible party; -Diagnoses include muscle weakness, fall, sacrum (tailbone) fracture and compression fracture of L2 (lumbar vertebra). Review of the resident's October 2024 POS showed an order for assist rails on both sides of the bed for positioning and to assist with mobility every day and night. Review of the resident's Baseline Care Plan, dated 10/21/24, showed the resident required one person for bed mobility and transfers. (The resident's care plan did not address use of bed rails/assist bars.) Review of the resident's Bed Rail/Assist Bar Evaluation, dated 10/23/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -The resident does not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? Yes, mechanical fall (an external force (e.g., environmental) caused the patient to fall); -Is the resident having problems with balance or poor trunk control? Yes; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The bilateral bed rails/assist bars are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Observation on 10/22/24 at 12:21 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. During interview on 10/23/24 at 2:31 P.M., the resident said he/she used the assist rails to help him/her turn over in bed. 3. Review of Resident #24's undated Face Sheet showed he/she had a power of attorney. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 03/19/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -The resident did not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to get in bed safely without assistance: No; -Is the resident able to get out of bed safely without assistance: No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes -fall leading to hospitalization ; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Summary of findings: The resident is cognitively intact. The summary did not indicate what type of bed rail would be used, that the resident requested bed rails or that the family and physician were notified. -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's Care Plan, last revised 07/22/24, showed the following: -Assist of one to two staff for bed mobility and transfers due to impaired mobility and impaired balance; -Assist rails on both sides of bed; -Assist bars make it possible for the resident to reposition himself/herself in bed, assist the resident with transfers in and out of bed, and to be more independent. Review of the resident's POS, dated October 2024, showed the following: -Diagnoses included dementia and multiple sclerosis; -Weight bearing as tolerated with sit to stand lift. -No order for assist rails. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers; -Required substantial to maximum assistance with bed mobility. Observation on 10/24/25 at 2:37 P.M. showed the resident lay in his/her bed with assist rails in the raised position on both sides of the bed. The left side of the bed was up against the wall. 4. Review of Resident #25's Bed Rail/Assist Bar Evaluation, dated 04/19/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -The resident did not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to get in bed safely without assistance: No; -Is the resident able to get out of bed safely without assistance: No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes -fall with a non displaced right femur fracture; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? Not addressed either way; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has moderately impaired cognition. The resident requested the use of bilateral assist rails to serve as an enabler to promote independence. -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Supervised or touch assist with bed mobility; -Substantial to maximum assist for transfers. -Impaired ROM one lower extremity. Review of the resident's Care Plan, last revised 07/29/24, showed the following: -Assist rails on both sides of bed per resident request; -Assist rails will assist the resident with repositioning in bed and with transferring in and out of bed; -The resident was aware of the risks involved with the assist rails and signed a consent; -Therapy evaluated the resident for appropriateness for assist rails, indicating they will serve as an enabler to promote independence. Review of the resident's POS, dated 10/2024, showed the following: -Diagnoses included osteoarthritis (flexible tissue at ends of bones wears down, causing pain), periprosthetic fracture (broken bone occurring near or around an orthopedic implant) around internal prosthetic right hip joint and muscle weakness; -Order for for assist rails on both sides for positioning and to assist with mobility (original order dated 4/19/24). Observation on 10/24/24 at 7:12 A.M. showed the resident lay in his/her bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. The right side of the bed was pushed against the wall. 5. Review of Resident #23's undated face sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include hemiplegia and hemiparesis following hemorrhage affecting right dominant side (weakness or paralysis affecting the right side only after a brain bleed) and orthostatic hypotension. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 09/06/24, showed the following: -Assessment was an admission and readmission assessment for bilateral assist bar/bed rail; -The resident had fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes - no explanation noted; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No (Staff did not answer this questions correctly as the resident had a diagnosis of orthostatic hypotension); -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has requested to have bed rails/assist bar while in bed and bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion to the upper and lower extremities one side of his/her body; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on 09/19/24, showed the following: -He/She required assistance with activities of daily living (ADLs) related to impaired mobility and impaired balance; -Assist him/her with repositioning every two to three hours and as needed with assistance of one; -Assist rails as ordered for mobility; -He/She required assistance from one to two staff for transfers. Review of the resident's October 2024 POS showed an order for assist rails on both sides of the bed for positioning and to assist with mobility every day and night. Observation on 10/22/24 at 11:28 A.M., showed the resident lay in bed awake with 1/8th assist rails in the raised position on both sides of his/her bed. The rail was stationary and unable to be lowered. During an interview on 10/22/24 at 11:28 A.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Observation on 10/24/24 at 5:10 A.M., showed the resident lay in bed sleeping with 1/8th assist rails in the raised position on both sides of his/her bed. 6. Review of Resident #207's undated face sheet showed the following: -The resident was his/her own responsible party; -Diagnoses included wedge compression fracture of T9-T10 vertebra (a break in the thoracic spine that occurs when the vertebrae collapse under pressure), dementia (a group of thinking and social symptoms that interferes with daily functioning) and anxiety disorder. Review of the resident's October 2024 POS showed an order for assist rail on both sides of the bed for positioning and to assist with mobility every day and night shift for cane rails. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 10/21/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? If yes, explain. Yes - fall (have) self-transfer; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: Assist bar/bed rails: bilateral. Bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Observation on 10/22/24 at 2:10 P.M., showed the resident's bed had 1/8th assist rails in the raised position on both sides of the bed. The rail was stationary and unable to be lowered. During an interview on 10/22/24, at 2:10 P.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No impairment in his/her range of motion; -Used wheelchair and walker; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers; -History of falls prior to admission, fall within the last 2-6 months prior to admission, fracture related to fall in six months prior to admission; -No falls since admission. Review of the resident's Care Plan, revised on 10/23/24, showed the following: -He/She was at risk for falls related to impulsiveness and gait/balance problems; -The resident/resident's family had requested assist bars to be on the sides of his/her bed; -He/She was informed of the risks involved in having assist bars and the resident signed a consent form that he/she was aware and still wanted them; -He/She will be re-evaluated if there is a change in status; -On 10/22/24 at 3:44 P.M., staff observed the resident sitting on the floor in his/her room between the wheelchair and bed. Observation on 10/24/24 at 5:11 A.M., showed the resident lay in bed sleeping with 1/8th assist rails in the raised position on both sides of his/her bed. 7. Review of Resident #4's undated Face Sheet showed the resident's diagnoses included muscle weakness, other abnormalities of gait and mobility, and falls. Review of the resident's Bed Rail/Assist Bar evaluation, dated 03/06/24, showed the following: -Assessment was marked as an other evaluation, but did not specify the reasoning; -The assist bar/bed rail is located on bilateral sides; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -Does the resident have fluctuation in levels of consciousness or a cognitive deficit? No; -Is the resident physically able to release bed rails/assist bar? No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have any visual deficits? No; -Is the resident able to get in bed safely without assistance? Yes; -Is the resident able to get out of bed safely without assistance? Yes; -Does the resident have a history of falls? Yes, one on 02/23/24; -Is the resident having problems with balance or poor trunk control? No; -Is the resident able to voluntarily move their own body? Yes; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a possibility the resident will climb over the bed rails/assist bar? No; -Is there evidence (reason to believe) the resident has (or may have) a desire to reason to get out of bed? No; -Does the resident receive any medications that would require safety precautions? No; -Is the resident continent of bowel and/or bladder? If no, explain: No, no explanation given; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risks than bed rails/assist bar use? No; -Will/does the bed rail/assist bar obstruct the resident's view? No; -Based on the summary of findings, signed by physical therapist on 05/01/24: the resident has requested to have bed rails/assist bar while in bed and the bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to one side of the upper extremities; -Required substantial to maximum assistance for all mobility needs. Review of the resident's Care Plan, revised 09/05/24, showed the following: -He/She required assistance with activities of daily living (ADLs) due to impaired mobility and impaired balance; -Assistance of one staff for repositioning every two or three hours and as needed; -He/She had assist rails to both sides of his/her bed; -Assist rails were to help him/her with positioning and mobility; -He/She had potential for injury related to impaired mobility; -Physical therapy evaluated if the assist rails would be a benefit for him/her; -He/She will be re-evaluated if there is a change in condition. Review of the resident's Physician's Order Sheet, dated October 2024, showed an order for assist rails on both sides for positioning and to assist with mobility every day and night. Observation on 10/24/25 at 5:10 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. 8. Review of Resident #45's undated Face Sheet showed the following: -admitted [DATE]; -Diagnoses of hemiplegia and hemiparesis affecting the left side, morbid obesity, and need for assistance with personal care; -The resident had a responsible party. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion on one side of upper and lower extremities; -Required moderate to substantial/maximal assistance for all mobility needs. Review of the resident's Care Plan, revised on 08/29/24, showed the following: -He/She required assistance with ADLs due to impaired mobility and impaired balance; -He/She had requested assist bars to both sides of his/her bed; -He/She was able to reposition himself/herself in bed and the assist bar with getting in and out of bed; -He/She will be reevaluated as needed; -Therapy had evaluated him/her for appropriateness of assist bars and it was indicated they enable him/her to be more independent. Review of the resident's bed rail/assist bar evaluation, dated 09/10/24, showed the following: -Assessment did not specify if it was an admission, readmission, quarterly, annual, significant change, or other evaluation; -The assist bar/bed rail is located on bilateral sides; -Has resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -Does the resident have fluctuation in levels of consciousness or a cognitive deficit? No; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have any visual deficits? No; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? No; -Is the resident having problems with balance or poor trunk? No; -Is the resident able to voluntarily move their own body? Yes; -Will/Does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a possibility the resident will climb over the bed rails/assist bar? No; -Is there evidence (reason to believe) the resident has (or may have) a desire to reason to get out of bed? No; -Does the resident receive any medications that would require safety precautions? No; -Is the resident continent of bowel and/or bladder? If no, explain. No, no desire to toilet; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risks than bed rails/assist bar use? No; -Will/Does the bed rail/assist bar obstruct the resident's view? No; -No page two with the summary of findings; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's POS, dated October 2024, showed an order for assist rail on both sides for positioning and to assist with mobility every day and night. Observation on 10/22/24 at 2:34 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/23/24 at 8:31 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/23/24 at 8:38 A.M. showed the Education/Staffing Director and Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) T repositioned the resident in bed. The resident did not utilize the assist rails as the staff worked together to move him/her up in his/her bed. Observation on 10/24/24 at 6:51 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/24/24 at 1:01 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. 9. During an interview on 10/31/24 at 9:04 A.M., Physical Therapy R said the following: -The current therapy company took over therapy at the facility one week before the annual recertification survey began; -The physical therapist or occupational therapist completed the bed rail/assist bar evaluations for new admissions and for any resident the facility requested it to be completed on; -The therapists completed a bed rail/assist bar evaluation on all residents admitted since the therapy company began at the facility, but he/she was unsure if ongoing assessments would be completed; -Ongoing assessments would be at the direction of the facility; -The residents' risk for entrapment was not evaluated as the rails being used were assist bars and not bed rails. During an interview on 10/25/24 at 10:34 A.M., the Director of Nursing (DON) said the therapy department completed the bed rail assessments on admission and as needed. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -The therapy department completed the assist bar assessments when a resident was admitted ; -He did not feel like there were any rails in the facility that were classified as bed rails. The rails used were assistive devices for positioning; -He was unsure how often the therapy department completed the assessments other than on admission. 32899 42592 50189

Based on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for eight residents (Residents #24, #12, #39, #27, #102, #103, #202, and #42), in a review of 20 sampled residents. Staff failed to failed to utilize Enhanced Barrier Precautions (EBP) during personal care for three residents (Residents #24, #12, and #39) who had urinary catheters (a tube inserted into the bladder to drain urine); failed to maintain a system to ensure one resident's (Resident #24's) urinary catheter tubing and dignity bag (containing the urinary drainage bag) were kept off the floor; failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #27); failed to ensure nebulizer masks (mask used to administer breathing treatments) and CPAP (a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders) masks were covered when not in use for three residents (Residents #102, #103 and #202); and failed to ensure staff used proper technique and hand hygiene during a medication pass for one resident (Resident #42). The facility census was 49. Review of the facility's undated policy, Enhanced Barrier Precautions, showed the following: -It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms; -Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; -Policy explanation and compliance guidelines: -All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -Initiation of Enhanced Barrier Precautions: -The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC; -An order for enhanced barrier precautions will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism); -Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; -Implementation of Enhanced Barrier Precautions: -Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e. wound irrigation, tracheostomy care); -Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy, Urinary Catheter Care, last revised August 2022, showed the following: -The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections; -Use aseptic technique when handling or manipulating the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #24's Care Plan, last revised 08/08/24, showed the following: -Urinary catheter due to neurogenic bladder (urinary condition where someone does not have bladder control) and urinary retention (difficulty urinating and completely emptying the bladder); -Will remain free from infection; -Place urine collection bag in privacy bag when out of bed; -Hang urine collection bag from the side of the bed, away from the door when in bed. Review of the resident's Physician Order Sheets (POS), dated 10/2024, showed to change urinary catheter monthly. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/05/24, showed the following: -Indwelling urinary catheter; -Dependent for transfers; -Substantial to maximum assist with bed mobility and dressing; -Used a wheelchair. Observation on 10/23/24 at 8:15 AM. showed the resident sat in his/her wheelchair in the dining room where the dignity bag, which contained the urinary catheter drainage bag, hung from the back of the chair and touched the floor. Observations on 10/24/24 showed the following: -At 12:35 P.M., the resident lay in his/her bed. The resident's urinary catheter drainage bag hung from the right side of the bed and the catheter tubing (which contained yellowish urine) lay on the floor; -At 1:30 P.M., the urinary catheter tubing remained on the floor. During an interview on 10/25/24, at 12:50 P.M., the Director of Nurses (DON) said she expected staff to keep catheter bags and tubing off of the floor. Observation on 10/24/24 at 2:37 P.M. showed the following: -There was no signage to indicate the resident was on EBP outside the resident's room and no cart with PPE located outside or near the resident's room. -The resident lay in the bed and the catheter tubing (which contained yellow urine) remained on the floor; -Licensed Practical Nurse (LPN) L and Certified Medication Technician (CMT) O entered the room and performed perineal care and catheter care on the resident; -Neither staff wore a gown. During an interview on 10/25/24 at 12:15 P.M., CMT O said the following: -He/She was not sure what EBP was; -He/She thought it would be used when working with anyone with infections, contagious blood or any bodily fluids and would include gowns, gloves and a face shield or goggles. 2. Review of Resident #12's significant change in status MDS, dated [DATE], showed the following: -Urinary catheter; -Dependent on staff for hygiene and to roll right to left in bed; -Application of dressing to feet. Review of the resident's Nurses Notes, dated 10/9/24, showed the wound nurse practitioner visited on 10/8/24. Left lateral foot 0.8 centimeters (cm) by 1.0 cm by eschar (dead tissue that eventually sloughs off healthy skin after an injury). Today maintenance will add padding to wheelchair foot rests. Review of the resident's Care Plan, last revised 10/23/24, showed the following: -The resident had a suprapubic catheter related to neurogenic bladder and urinary retention; -Provide catheter care as ordered; -Cleanse the suprapubic drain site with normal saline or soapy water, pat dry, apply new dressing and secure. It is to be done daily and as needed; -The resident was at risk for impaired skin integrity due to pressure areas; -Left lateral (outside) foot 0.6 centimeters (cm) by 0.8 cm by 0.2 cm. Treatment of mupirocin 2% ointment (antibiotic ointment used for skin infections), alginate/bordered form (absorbent dressing) three times a week and as needed. (The resident's care plan did not identify the need for or use of EBP when providing care for resident.) Review of the resident's POS, dated October 2024, showed the following: -Change suprapubic catheter once monthly on the 15th; -Cleanse suprapubic drain site with normal saline or soapy water, pat dry. Apply drain dressing daily and as needed for dislodgement; -Catheter care every shift; -Obtain catheter output every shift; -Mupirocin 2% ointment to left lateral foot every day shift on Monday, Tuesday and Thursday for wound. Cleanse left lateral foot, apply mupirocin ointment 2% and alginate cover with ordered form three times per week and as needed. Review of the resident's nurses note, dated 10/22/24, showed the wound nurse practitioner documented left lateral foot 0.6 cm by 0.8 cm by 0.2 cm, 100% yellow, treatment mupirocin 2% ointment, alginate with bordered foam three times a week and as needed. Observation on 10/22/24 at 2:18 P.M., showed the resident sat in his/her wheelchair in his/her room. There was no signage to indicate the resident was on EBP outside the resident's room and no cart with personal protective equipment (PPE) located outside or near the resident's room. Observation on 10/23/24 at 2:16 P.M., showed the resident sat in his/her bed in his/her room. There was no signage outside the resident's room and no cart with PPE located outside or near the resident's room. During interview on 10/23/24 at 2:16 P.M., the resident said staff do not wear gowns when providing cares. Staff only wear gloves when providing care. Observation on 10/24/24 at 12:00 P.M., showed the following: -Registered Nurse (RN) A and the Infection Preventionist (IP) entered the resident's room; -The resident lay on his/her back in bed; -RN A and the IP washed their hands and put on gloves; -RN A removed the dressing from the wound on the resident's left foot; -There was a scant amount of yellowish drainage; -RN A removed his/her gloves, used hand sanitizer, and put on new gloves; -RN A cleansed the resident's wound with wound cleanser and 4x4 gauze; -While RN A washed his/her hands and changed his/her gloves, the IP applied mupirocin 2% ointment to the wound; -RN A applied alginate to the wound and covered the wound with a bordered bandage; -RN A and the IP washed their hands and changed gloves; -RN A cleaned around the resident's suprapubic catheter insertion site with a soapy washcloth, cleaned around the site again with another wet washcloth, dried the area with a towel and placed a split sponge around the catheter tubing and secured the dressing with tape; -RN A and the IP did not wear a gown while providing treatment to the wound on the resident's foot and when providing catheter care. During an interview on 10/25/24 at 9:11 A.M., RN A said the following: -The facility did not have any current residents on EBP; -EBP was used for things like COVID-19, diarrhea, surgical incisions, MRSA (methicillin-resistant staphylococcus aureus)/VRSA (vancomycin-resistant staphylococcus aureus), pressure wounds and any wound with a wound vac; -EBP was indicated by a sign and EBP supply cart outside the room door, as well as information passed on in report. During interview on 10/25/24 at 9:16 A.M., the IP said the following: -The facility had no residents on EBP; -The facility policy said if a resident had MRSA, ESBL (Extended Spectrum Beta-Lactamase - an enzyme produced by some bacteria that may make then resistant to some antibiotics), VRE (VRE are resistant to vancomycin, the drug often used to treat infections caused by enterococci) or C-diff (a bacterium that causes an infection of the colon) then staff would need to wear gown, gloves and mask when providing direct care and there would be signage outside the resident's room; -She was aware of the new guidance for EBP to also include chronic wounds, G-tubes (a tube inserted through the belly that brings nutrition directly to the stomach), catheters and ports (port-a-cath is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs) but this was not the facility's policy. 3. Review of Resident #39's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Urinary catheter. Review of the resident's Care Plan, revised on 09/04/24, showed the following: -The resident had a urinary catheter; -Change urinary catheter monthly. Review of the resident's Physician's Orders, dated October 2024, showed the following: -Change urinary catheter every month on the 27th; -Urinary catheter care every shift; -Obtain urinary catheter output every shift, day and night. Observation on 10/22/24 at 1:41 P.M. showed no EBP signage on or near the resident's room door and no PPE available near the resident's room. During an interview on 10/23/24 at 8:49 A.M., the resident said staff always wore gloves when providing care, but he/she never saw staff wear a gown or mask when providing care to his/her catheter. Observation on 10/24/24 at 12:42 P.M., showed the following: -CNA K washed his/her hands, donned gloves, and assisted the resident to walk from the reclining chair to the bed using a walker and gait belt; -CNA K pulled down the resident's pants and asked him/her to sit on the bed; -CNA K and CNA U removed the resident's shoes and assisted the resident to lay in bed; -CNA U provided perineal care and catheter care for the resident. CNA U did not wear a gown; -CNA K drained the urine from the urinary catheter drainage bag into a urinal. CNA K wore gloves, but did not wear a gown or face protection (as directed by facility policy when performing an activity with risk of splash or spray); -CNA U wiped the tip of the urinary catheter drain with a wipe, placed it back in the holder, removed his/her gloves, and washed his/her hands; -CNA K dumped the urinal into the toilet; -CNA U placed shoes on the resident; -CNA K helped the resident to stand using a gait belt and walker, then pulled up the resident's pants; -CNA U helped the resident walk from the bed to the recliner using a gait belt and walker. -CNA U and CNA K did not wear a gown when providing care to the resident who had a urinary catheter. During an interview on 10/25/24 at 12:29 P.M., CNA K said the following: -He/She was aware of what EBP was from a training he/she received; -Any resident with an open wound, a catheter, or certain types of infections should be on EBP; -Most EBP required a gown and gloves, and some required masking as well; -If a resident was on EBP, they would have a sign on their door stating they were on EBP and they would have a PPE cart outside of their room door; -He/She was not aware of any resident who was currently on EBP; -Resident #39 should be on EBP because of his/her urinary catheter. 4. During an interview on 10/25/24 at 12:20 P.M., CNA N said the following: -The nurse would alert staff as to when EBP should be used; -EBP would include the use of a gown, gloves and a mask and would be stored in a container outside of the room; -He/She had been educated to use EBP if a resident had a wound, a catheter, or a feeding tube; -The EBP would be worn at all times when providing cares; -There were no residents requiring the use of EBP at this time as nursing had not directed staff to use them. During an interview on 10/25/24 at 12:06 P.M., the Education/Staffing Director said the following: -The facility policy for EBP was only for qualifying infections; -Catheters and wounds in general did not qualify for EBP, unless the resident had an active infection that met the facility criteria; -If a resident was on EBP, they would have a sign on their door that showed they were on EBP and the PPE requirements, and they would have a PPE cart outside of their room. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -EBP was used with infections and if the physician requested it; -Staff was made aware of EBP being used by a meeting, group talk, the sign outside the door and the EBP cart outside the resident's door; -No residents were on EBP at present. During an interview on 10/25/24 at 12:50 P.M., the DON said the following: -There were currently no residents on EBP; -EBP was used if there was a catheter or wound that had a microorganism that had been identified; -If a resident had a chronic wound or catheter, that didn't not necessarily constitute EBP, it depended on the organism in the wound/urine/etc.; -She expected staff to follow the facility policy for EBP; -The facility policy did not identify each person with a catheter or wound would be on EBP; -The facility should follow the Center for Disease Control (CDC) guidelines for EBP; -She was unaware of the current CDC or Centers for Medicare and Medicaid Services (CMS) recommendations related to EBP. During an interview on 10/25/24, at 1:15 P.M., the Administrator said the following: -The only time EBP was used was if there was some type of infection that would be problematic, otherwise EBP was not used routinely; -He was aware there had been talks of changes related to EBP, but was unaware changes had been made by CDC or CMS; -The facility should follow the guidelines from CDC and CMS related to EBP; -The facility was currently following their policy related to infections. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2019, showed the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before preparing or handling medications; before performing any non-surgical invasive procedures; before and after handling an invasive device (e.g., urinary catheters, IV access sites); before donning sterile gloves; before handling clean or soiled dressing, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution settings; before and after eating or handling food; before and after assisting a resident with meals and after personal use of the toilet or conducting your own personal hygiene; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility policy, Personal Protective Equipment - Using Gloves, revised September 1010, showed the following: -Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed; -Wash your hands before and after removing gloves. (Note: Gloves do not replace handwashing.); -Remove gloves before removing the mask and gown and discard them into the designated waste receptacle inside the room. 5. Review of #27's admission MDS, dated [DATE], showed the following: -Supervision to touch assist for bed mobility, transfer and toileting; -Occasionally incontinent of bladder; -Used a wheelchair. Review of the resident's care plan, dated 08/30/24, showed the following: -Occasionally incontinent of bladder; -Assist of one staff for hygiene, toileting, dressing, bed mobility and transfers; -Used a wheelchair. Observation on 10/24/24 at 5:19 A.M. showed the following: -The resident lay on a urine soaked cloth pad and disposable pad on his/her back in the bed; -Certified Nurse Aide (CNA) J entered the room, and without washing hands, put on gloves; -He/She exited the room while wearing the gloves, returned with plastic bags and placed a bag in the trash can; -He/She put on a second pair of gloves over the first pair; -He/She rolled the resident to his/her left side by touching the resident's hip area, rolled the urine soiled pads underneath the resident, wiped the resident's urine soiled back side with incontinent wipes; -Without removing his/her gloves, CNA J placed a clean incontinence brief under the resident, rolled the resident, secured the brief, picked up the resident's pants and put them on the resident, assisted the resident to sit on the side of the bed, and put socks and shoes on the resident; -He/She removed his/her gloves, and without washing or sanitizing his/her hands, put on new gloves; -He/She took the pajama top off the resident, put a clean shirt on the resident, and then transferred the resident to the wheelchair. -CNA J then removed his/her gloves and washed his/her hands. During an interview on 11/5/24 at 10:36 A.M., CNA J said the following: -He/She should wash his/her hands before cares, after perineal care, with gloves changes and when moving from a dirty to clean task; -He/She should change his/her gloves when they become soiled, after perineal care, and after touching trash. During an interview on 10/25/24, at 12:50 P.M., the DON said the following: -She expected staff to change their gloves during resident care when they become soiled; -She expected staff to wash their hands to be washed when they enter a resident care area, when they change their gloves, and when care was completed. Staff could use hand sanitizer between changing gloves. Review of the facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2001 and last revised October 2010, showed the following: -The purpose of this procedure is to safely and aseptically administer aerosolized particles of medications into the resident's airway; -Rinse and disinfect the nebulizer equipment according to facility protocol, or: -Wash pieces with warm soapy water; - Rinse with hot water; -Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes); -Rinse all pieces with sterile water (NOT tap, bottles or distilled); and -Allow to air dry on a paper towel; -When equipment is completely dry, store in a plastic bag with the resident's name and date on the bag. The facility did not have a policy directing staff how to store CPAP masks when not in use. 6. Review of Resident #102's POS, dated October 2024, showed the following: -admitted [DATE]; -CPAP to be worn at bedtime per home settings; -Diagnoses included obstructive sleep apnea (episodes of a complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep) and cardiomyopathy (causes the heart to lose its ability to pump blood well). Review of the resident's Care Plan, dated 10/22/24, showed no evidence the resident used CPAP at bedtime. Observation on 10/23/24 at 2:31 P.M., showed the resident's CPAP mask lay uncovered on the bedside table. Observation on 10/24/24 showed the following: -At 5:15 A.M., the resident lay on his/her back in bed with his/her eyes closed. The CPAP mask was on the resident's face; -At 5:30 A.M., the resident lay in his/her bed on his/her back with his/her eyes closed. The CPAP mask lay uncovered on the bedside table; -At 9:39 A.M., the resident's CPAP mask lay uncovered in the same location on the bedside table. 7. Review of Resident #103's POS, dated October 2024, showed the following: -Readmitted [DATE]; -Continuous supplemental oxygen at 2 to 4 liters per nasal cannula; -Albuterol Sulfate inhalation 2.5 mg per milliliter (ml) 0.083%, 3 ml orally via nebulizer every six hours as needed for asthma or COPD; -Diagnoses included acute on chronic respiratory failure, dependence on supplemental oxygen, and lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung). Review of the resident's Care Plan, dated 10/20/24, showed the following: -The resident was on oxygen therapy related to respiratory illness; -Oxygen via nasal cannula at 2 to 4 liters continuously. Observation on 10/22/24 showed the following: -At 11:23 A.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay uncovered on the bedside table; -At 12:19 P.M., the resident sat on the side of the bed for lunch with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table; -At 4:55 P.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay uncovered on the bedside table. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Cognitively intact; -Oxygen therapy; -Diagnoses included COPD and pneumonia. Observation on 10/23/24 showed the following: -At 8:57 A.M., the resident sat on the side of the bed for breakfast with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table; -At 2:26 P.M., the resident sat on the side of the bed with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table. Observations on 10/24/24 showed at 5:10 A.M., 7:48 A.M. and 9:39 A.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay on the bedside table uncovered. 8. Review of Resident #202's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included acute and chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body that can be all at once or come on over time), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (occurs when your breathing is interrupted during sleep, sometimes for longer than 10 seconds). Review of the resident's October 2024 POS showed an order for CPAP at bedtime every night shift. Review of the resident's Baseline Care Plan, dated 10/18/24, showed the resident used a CPAP. Observation on 10/22/24 at 1:57 P.M., showed the resident's CPAP mask lay uncovered on the resident's bed near his/her pillow. During interview on 10/22/24 at 1:57 P.M., the resident said he/she took care of his/her CPAP equipment and had not had it covered since admission. Observation on 10/23/24 at 8:45 A.M., showed the resident's CPAP mask lay uncovered on top of the resident's bed pillow. Observation on 10/24/24 at 7:36 A.M., showed the resident's CPAP mask lay uncovered on the resident's bed near his/her pillow. 9. During an interview on 10/25/24 at 9:11 A.M., RN A said oxygen supplies like nasal cannulas and CPAP masks should be covered with a clear bag when not in use. During interview on 10/25/24 at 9:16 A.M., the IP said nebulizer masks and CPAP masks should be on a towel or paper towel when not in use or in a bedside table drawer. During an interview on 10/25/24 at 12:50 P.M., the DON said she expected CPAP masks to be stored in a plastic bag when not in use. The masks should not be left sitting on the bed or bedside table. Review of the facility's policy, Administering Oral Medications, dated 2001 and last revised October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medication; -Do not touch the medication with your bare hands; -If a medication falls to the floor, discard and document per facility protocol. 10. Review of Resident #42's POS, dated October 2024, showed the following: -Coreg (medication used to treat high blood pressure) 25 milligrams (mg) by mouth twice daily; -Anagrelide HCL (a medication used to decrease blood clots) 0.5 mg by mouth Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Observation on 10/23/24 at 8:24 A.M., showed the following: -CMT P sanitized his/her hands, opened the medication drawer and retrieved a prepackaged slip of medications containing both Coreg and the anagrelide; -CMT P placed the prepackaged slip of medications back into the medication drawer. As he/she laid the slip into the drawer, two white pills fell out of the package and into the medication drawer; -With his/her bare hands, CMT P picked up the two pills and lay them on top of the prepackaged slip and closed the medication cart drawer; -CMT P walked over to Resident #42 and obtained his/her blood pressure; -CMT P walked back to the medication cart, sanitized his/her hands, opened the medication cart drawer, picked up the two white pills with his/her bare hands, and placed them in a medication cup; -CMT P prepared the rest of the resident's morning medication and administered all the medications, including the two medications that lay directly in the medication cart drawer, to the resident. During interview on 10/23/24 at 2:25 P.M., CMT P said he/she shouldn't have touched the pills with his/her bare hands. He/She thought since the pills fell in the medication drawer, they were okay to give to the resident. If the pills had fallen on top of the medication cart, then he/she would have discarded them and gave the resident new pills. During an interview on 10/25/24, at 12:50 P.M., the DON said if a medication fell out of a pill packet and dropped into the medication cart, she would expect staff to discard the pill and get a new pill to administer to the resident. 32899 42592 50189

Based on observation, interview and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Resident #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on [DATE], showed the following: -Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; -The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised [DATE], showed the following: -Between 1985 and [DATE], 803 incidents of residents getting caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported, 480 died and 138 had non-fatal injuries; -Most residents were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when residents, or parts of their body, are caught between rails and mattresses, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #12's undated Face Sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and weakness. Review of the resident's Bed Rail/Assist Bar Evaluation, dated [DATE], showed the resident requested to have bed rails/assist bar while in bed, and bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the facility provided documentation of Entrapment Assessment showed the last entrapment assessment was completed on [DATE]. The assessment did not show measurements, only four zones and pass/fail status. All the areas indicated as passed for the room the resident was assigned to. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion impairment on the upper and lower extremities on both sides of his/her body; -The resident was dependent on staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfers. Review of the resident's care plan, revised on [DATE], showed the following: -He/She required assistance with activities of daily living (ADL's) related to mobility and impaired balance; -Assist bars are for mobility and transfer on his/her bed. Observation on [DATE] at 2:16 P.M., showed the resident lay in bed. The resident had ,d+[DATE]th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 2. Review of Resident #102's undated Face Sheet showed his/her admitted was [DATE]. Review of the resident's baseline care plan, dated [DATE], showed the following: -Required one person for bed mobility and transfers; -The care plan did not address use of side rails/assist bars. Review of the resident's Bed Rail/Assist Bar Evaluation, dated [DATE], showed bilateral bed rails/assist bars were indicated and would serve as an enabler to promote resident independence. Observation on [DATE] at 12:21 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had ,d+[DATE]th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 3. Review of Resident #24's Bed Rail/Assist Bar Evaluation, dated [DATE], showed staff completed an admission assessment for bilateral assist bar/bed rail. The assessment did not identify if assist bars/bed rails were indicated. Review of the resident's Care Plan, last revised [DATE], showed the following: -Assist of one to two staff for bed mobility and transfers due to impaired mobility and impaired balance; -Assist rails on both sides of bed; -Assist bars make it possible for the resident to reposition himself/herself in bed, assist the resident with transfers in and out of bed, and to be more independent. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers; -Required substantial to maximum assistance with bed mobility. Observation on [DATE] at 2:37 P.M. showed the resident lay in his/her bed with assist rails in the raised position on both sides of the bed. The left side of the bed was up against the wall. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 4. Review of Resident #25's Bed Rail/Assist Bar Evaluation, dated [DATE], showed the resident requested the use of bilateral assist rails to serve as an enabler to promote independence. Staff completed an admission assessment for the bilateral assist bar/bed rail. The assessment did not identify if assist bars/bed rails were indicated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Supervised or touch assist with bed mobility; -Substantial to maximum assist for transfers. -Impaired ROM one lower extremity. Review of the resident's Care Plan, last revised [DATE], showed the following: -Assist rails on both sides of bed per resident request; -Assist rails will assist the resident with repositioning in bed and with transferring in and out of bed; -The resident was aware of the risks involved with the assist rails and signed a consent; -Therapy evaluated the resident for appropriateness for assist rails, indicating they will serve as an enabler to promote independence. Observation on [DATE] at 7:12 A.M. showed the resident lay in his/her bed. The resident had ,d+[DATE]th assist rails in the raised position on both sides of his/her bed. The right side of the bed was pushed against the wall. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 5. Review of Resident #23's Bed Rail/Assist Bar Evaluation, dated [DATE], showed he resident requested to have bed rails/assist bar while in bed and bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion to the upper and lower extremities one side of his/her body; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on [DATE], showed the following: -He/She required assistance with activities of daily living (ADLs) related to impaired mobility and impaired balance; -Assist rails as ordered for mobility. Observation on [DATE] at 11:28 A.M., showed the resident lay in bed awake with ,d+[DATE]th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no evidence of measurements or evaluation for entrapment zones on the resident's bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 6. Review of Resident #207's Bed Rail/Assist Bar Evaluation, dated [DATE], showed staff completed an admission assessment for bilateral assist bar/bed rails. Bed rails/assist bar were indicated and would serve as an enabler to promote resident independence Observation on [DATE] at 2:10 P.M., showed the resident's bed had ,d+[DATE]th assist rails in the raised position on both sides of the bed. The rail was stationary and unable to be lowered. During an interview on [DATE], at 2:10 P.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers; -History of falls prior to admission, fall within the last ,d+[DATE] months prior to admission, fracture related to fall in six months prior to admission; -No falls since admission. Review of the resident's Care Plan, revised on [DATE], showed the following: -He/She was at risk for falls related to impulsiveness and gait/balance problems; -The resident/resident's family had requested assist bars to be on the sides of his/her bed; -He/She was informed of the risks involved in having assist bars and the resident signed a consent form that he/she was aware and still wanted them; -He/She will be re-evaluated if there is a change in status; -On [DATE] at 3:44 P.M., staff observed the resident sitting on the floor in his/her room between the wheelchair and bed. Observation on [DATE] at 5:11 A.M., showed the resident lay in bed sleeping with ,d+[DATE]th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 7. Review of Resident #4's face sheet showed the following: -admitted : [DATE]; -Diagnoses of muscle weakness, other abnormalities of gait and mobility, and unspecified falls. Review of the resident's Bed Rail/Assist Bar evaluation, dated [DATE], showed the resident had requested to have bed rails/assist bar while in bed and the bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the facility provided documentation of Entrapment Assessments, showed the last entrapment assessment was completed [DATE]. The assessment does not show measurements, only four zones and pass/fail status. All areas indicated as passed for the room the resident was currently assigned to. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to one side of the upper extremities, no impairment in the lower extremities; -Substantial to maximum assistance for all mobility needs. Review of the resident's Care Plan, revised [DATE], showed the following: -He/She required assistance with activities of daily living (ADLs) due to impaired mobility and impaired balance; -Assistance of one staff for repositioning every two or three hours and as needed; -He/She had assist cane rails to both sides of their bed; -Assist rails are to help him/her with positioning and mobility; -He/She had potential for injury related to impaired mobility; -Physical Therapy evaluated if the assist rails would be a benefit for him/her; -He/She will be re-evaluated if there is a change in condition. Observation on [DATE] at 5:10 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 8. Review of Resident #45's face sheet showed the following: -admitted [DATE]; -Diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and/or facial muscles) affecting the left side, morbid obesity, and need for assistance with personal care. Review of the facility provided documentation of Entrapment Assessments, showed the last entrapment assessment was completed [DATE]. The assessment did not show measurements, only four zones and pass/fail status. The room the resident was currently assigned to was listed as having no bed rails. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion on one side of upper and lower extremities; -Required moderate to substantial/maximal assistance for all mobility needs. Review of the resident's Care Plan, revised on [DATE], showed the following: -He/She required assistance with ADLs due to impaired mobility and impaired balance; -He/She had requested assist bars to both sides of his/her bed; -He/She was able to reposition himself/herself in bed and the assist bar with getting in and out of bed; -He/She will be reevaluated as needed; -Therapy had evaluated him/her for appropriateness of assist bars and it was indicated they enable him/her to be more independent. Review of the resident's bed rail/assist bar evaluation, dated [DATE], showed staff did not identify the type of assessment (i.e. admission, quarterly, annual, etc) and did not identify if bed rails were indicated. Observation on [DATE] at 2:34 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 9. During an interview on [DATE] at 11:55 A.M., the Maintenance Director said the following: -A staff member who no longer worked at the facility completed the entrapment risk assessments on [DATE]; -No one had completed as assessment, including measurements of the bed frame, mattresses or side rails, since [DATE]; -There was a tool to measure the beds, but he had not used the tool to do any measurements; -He was unaware of how often staff should assess the beds for risk of entrapment. During an interview on [DATE] at 10:34 A.M., the Director of Nursing (DON) said maintenance staff measured the beds with bed rails for entrapment zones when therapy approved the bed rails. During an interview on [DATE] at 1:15 P.M., the Administrator said the following: -Maintenance staff was responsible for measuring the entrapment zones; -There had been no ongoing assessments for risk of entrapment; -The assist rails were a positioning device and not a bed rail. 42592 50189

Based on observation, interview, and record review, the facility failed to ensure staff safely transported residents in wheelchairs for four residents (Residents #26, #27, #25, and #4), in review of 19 sampled residents, and for two additional residents (Residents #11 and #40). The census was 49. During an interview on 11/05/24 at 10:19 A.M., the Director of Nursing (DON) said the facility did not currently have a policy for transporting residents in wheelchairs or the use of wheelchair foot rests. 1. Review of Resident #26's undated face sheet showed the resident's diagnoses included difficulty in walking, unsteadiness on feet, psychoactive substance-induced sleep disorder, history of falls, major depression, anxiety disorder, and mild cognitive impairment. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/25/24, showed the following: -Severe cognitive impairment; -Impaired range of motion to one side of the lower extremities; -Used a manual wheelchair; -Dependent on staff for transfers; -Supervision or touching assistance to wheel 50 to 150 feet once seated. Review of the resident's Care Plan, revised 10/10/24, showed the following: -Alert with periods of forgetfulness; -Diagnosis of dementia; -Required assistance with all activities of daily living (ADLs); -Limited physical mobility related to weakness and poor balance; -Impulsive at times, related to dementia; -High risk for falls, related to gait and balance problems; -Ensure appropriate footwear or non-skid socks worn, when ambulating or mobilizing in wheelchair. -Not to be left alone while up in wheelchair. Observation on 10/23/24 at 9:26 A.M. showed Certified Nurse Assistant (CNA) T pushed the resident in his/her wheelchair from the dining area to his/her room, approximately 50 feet, without foot rests on the wheelchair. The resident wore house slippers and his/her feet dragged on the carpeted floor for the duration of the transport. Observation on 10/24/24 at 1:15 P.M. showed CNA K pushed the resident in his/her wheelchair from the dining area to his/her room, approximately 50 feet, without foot rests on the wheelchair. The resident wore house slippers, and held his/her feet up approximately one inch off the floor during the transport. Observation on 10/24/24 at 1:20 P.M. showed CNA K pushed the resident in his/her wheelchair from his/her room to the dining area, approximately 50 feet, without foot rests. The resident wore house slippers, and held his/her feet up approximately one inch off the floor during the transport. 2. Review of Resident #27's admission MDS, dated [DATE], showed the following: -Supervision or touch assist with transfers; -Used a manual wheelchair; -Partial to moderate assist needed to wheel 50 to 150 feet in wheelchair once seated. Review of the resident's Care Plan, dated 08/30/24, showed the following: -Assist of one staff for transfers due to impaired mobility and balance; -Wheelchair is main mode of transportation; -Assist of one staff to propel (in wheelchair). Review of the resident's Physician Order Sheets (POS), dated October 2024, showed the following: -Diagnoses included cognitive deficit, history of falls and right femur (thigh bone) fracture; -Weight bearing as tolerated to right lower extremity. Observation on 10/24/24 at 5:19 A.M., showed Certified Medication Technician (CMT) J pushed the resident out of his/her room to the dining room without any foot rests on the wheelchair. The resident wore tennis shoes. CMT J did not instruct the resident to hold up his/her feet. The resident's toes were pointed downward and close to the floor. Observation on 10/25/24 at 12:41 P.M. showed an unidentified staff pushed the resident out of his/her room in his/her wheelchair without foot rests to the dining room. The resident's feet hovered just above the floor. Staff did not instruct the resident to raise up his/her feet. During an interview on 11/5/24 at 10:36 A.M., CMT J said staff should not push residents in their wheelchairs without foot rests because their feet could drag on the floor. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed the following: -Required substantial to maximum assist with transfers; -Impaired range of motion of one lower extremity; -Used a manual wheelchair; -Wheeled self (once seated) in wheelchair independently 50-150 feet. Review of the resident's care plan, last revised 7/29/24, showed the resident required extensive assist with activities of daily living and potential for injury related to impaired mobility, balance and history of falls. Review of the resident's POS, dated October 2024, showed the resident's diagnoses included displaced fracture of the right femur. Observation on 10/24/24 at 7:25 A.M. showed CNA N pushed the resident in his/her wheelchair, from his/her room to the dining room, without foot rests on his/her wheelchair. The resident wore non-skid socks and his/her feet hovered just off the floor. The staff did not direct the resident to lift his/her feet. During an interview on 10/25/24 at 12:20 P.M., CNA N said the following: -Staff should not push residents in wheelchairs without foot rests; -Residents who propelled themselves may not have foot rests, but they should be applied if staff need to push them; -Residents who self propelled did not have foot rests and in other cases the foot rests may be lost. 4. Review of Resident #4's undated face sheet showed the resident's diagnoses included muscle weakness, unsteadiness on feet, other abnormalities of gait and mobility, cognitive communication deficit, major depression, and falls. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impaired range of motion to one side of the upper extremities; -Used a manual wheelchair; -Required substantial to maximum assistance for all mobility; -Independent to wheel 50 to 150 feet once seated. Review of the resident's Care Plan, revised 09/05/24, showed the following: -Required assistance with all ADLs relate to impaired mobility and balance; -Required assistance or escort to activity functions; -Potential for injury related to falls and impaired mobility and balance; -Educated to wait for assistance; -Ensure wears proper fitting shoes that are supportive with non-skin soles for ambulation. Observation on 10/24/24 at 1:23 P.M. showed CNA K pushed the resident from the dining room to his/her room, approximately 75 feet, without foot rests on his/her wheelchair. The resident wore house shoes and his/her feet hovered just above the carpeted floor during the transport. 5. Review of Resident #11's undated face sheet showed the resident's diagnoses included function deficit following a stroke, other abnormalities of gait and mobility, psychosis, and dementia. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No impairment of range of motion in upper or lower extremities; -Used a manual wheelchair; -Required substantial to maximum assistance for all mobility; -Partial to moderate assistance to wheel 50 feet and make two turns, once seated; -Dependent to wheel up to 150 feet once seated. Review of the resident's Care Plan, revised 10/03/24, showed the following: -Required assistance with ADL care; -Wheelchair was main mode of transportation; -Assistance of one staff for wheelchair locomotion; -Alert with periods of forgetfulness related to dementia; -Potential for injury related to falls -Poor safety awareness; -Ensure proper fitting shoes that are supportive with non-skid soles for ambulation; -Offer frequent reminders and cues. Observation on 10/24/24 at 1:08 P.M. showed CNA K pushed the resident from the dining room to his/her room, without foot rests on his/her wheelchair. The resident wore house shoes and his/her feet hovered just above the carpeted floor during the transport. 6. Review of Resident #40's undated face sheet showed the resident's diagnoses included fall, dementia, psychotic disturbance, mood disturbance, muscle weakness, unsteadiness on feet, and cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Uses a manual wheelchair; -Supervision to touching assistance for all mobility; -Supervision to touching assistance to wheel 50 to 150 feet once seated. Review of the resident's care plan, revised 08/03/24, showed the following: -Assistance required for all ADLs related to impaired mobility and balance; -Alert with periods of forgetfulness; -Periods of disorganized thinking at times; -Wheelchair with one staff assistance for locomotion; -Potential for injury from falls related to impaired mobility and balance, history of falls and psychotropic drug use; -Ensure proper fitting shoes that are supportive with non-skid soles are worn for ambulation. Observation on 10/24/24 at 5:18 A.M. showed CNA Y pushed the resident in his/her wheelchair from his/her room to the dining room, without foot rests on his/her wheelchair. The resident wore house slippers and his/her feet hovered just above the carpeted floor during the transport. 7. During an interview on 10/25/24 at 9:32 A.M., CNA W said the following: -Many residents self propelled and did not like foot rests on their wheelchairs because they got in the way and they could not get close enough to the dining room tables for meals; -Residents told staff if they wanted foot rests on their wheelchairs; -Staff should not push residents in wheelchairs without foot rests. During an interview on 10/25/24 at 12:29 P.M., CNA K said if residents can hold their feet up, they don't need foot rests on their wheelchairs. During an interview on 10/25/24 at 12:06 P.M., the Education/Staffing Director said staff should not push residents in wheelchairs without foot pedals. During an interview on 10/25/24 at 1:00 P.M., the Director of Nurses said she expected staff to push residents in their wheelchairs with foot rests on the wheelchair. 50189

Based on interview and record review, the facility failed to provide two residents (Residents #4 and #26), or their responsible party, with a bed hold policy at the time of transfer to the hospital, in a review of 20 sampled residents. The facility census was 49. Review of the facility's policy, Bed Hold Policy, revised May 2024, showed the following when a resident was transferred to a hospital: -Neither a resident nor the responsible party is required to pay a nursing facility to hold a bed; -If the resident/responsible person chooses to, he/she may pay a nursing facility in order to reserve the same bed the participant is leaving; -A nursing home has an obligation to inform a resident or the responsible person that paying them to hold a bed is voluntary; -When a resident is transferred to a hospital, the nursing home is required, both by Federal statute and by Federal regulation, to readmit the resident immediately upon the first availability of a bed in a semiprivate room. 1. Review of Resident #4's undated Face Sheet showed the resident had a responsible party. Review of the resident's Progress Notes, dated 08/06/24 at 11:57 A.M., showed the resident was sent to the hospital at the family's request due to uncontrolled back pain. Review of the resident's Hospital Transfer Form, dated 08/06/24, showed the following: -The resident was transferred to the hospital on 08/06/24; -The resident's responsible party was notified of the clinical situation and the transfer. Review of the resident's Progress Notes, dated 08/06/24 at 6:13 P.M., showed the resident was admitted to the hospital. Review of the resident's Progress Notes, dated 08/13/24 at 5:55 P.M., showed the resident was readmitted to the facility at 4:30 P.M. Review of the resident's medical record showed no documentation staff provided the resident or his/her responsible party with a copy of the facility's bed hold policy/agreement at the time of the resident's transfer to the hospital on 08/06/24. 2. Review of Resident #26's undated Face Sheet showed he/she had a responsible party. Review of the resident's Progress Notes, dated 09/15/24 at 2:45 P.M., showed the resident was sent to the emergency room for extreme leg pain and shortening of leg, despite negative x-ray results. Responsible party was made aware. Review of the resident's Progress Notes, dated 09/15/24 at 10:07 P.M., showed the resident returned to the facility at 7:40 P.M. with a diagnoses of hip pain, but no hip fracture. Review of the resident's medical record showed no documentation staff provided the resident or his/her responsible party with a copy of the facility's bed hold policy/agreement at the time of the resident's transfer to the hospital on 09/15/24. Review of the resident's progress notes, dated 09/16/24 at 1:28 P.M., showed the emergency room called the facility to report the x-ray was read inaccurately and the resident did have a hip fracture and should return to the hospital. Review of the resident's Progress Notes, dated 09/16/24 at 3:46 P.M., showed the resident was sent to the hospital for a fracture of the left hip. The resident's responsible party was made aware of the transfer. Review of the resident's Progress Notes, dated 09/18/24 at 5:14 P.M., showed the resident was admitted back to the facility with a diagnoses of left hip fracture. Review of the resident's medical record showed no documentation staff provided the resident or his/her responsible party with a copy of the facility's bed hold policy/agreement at the time of the resident's transfer to the hospital on 09/16/24. 3. During an interview on 10/25/24 at 10:34 A.M. and 12:50 A.M., the Director of Nursing (DON) said she was not sure what was in the facility policy, as far as the timing of issuing the bed hold policy, but staff should provide notice of bed holds with every transfer to the hospital. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the facility should issue the bed hold notice as soon as the resident is sent to the hospital, but the facility will automatically hold the bed for 24 hours, to allow the facility time to contact the family, in the event they are not at the facility at the time of transfer. Residents/families were not required to hold their bed. If they want to hold the bed, the form was signed and social services was responsible for documenting the bed hold.

Based on interview and record review, the facility failed to review the baseline care plan with the resident/responsible party within 48 hours of admission or provide a copy of the baseline care plan to the resident/responsible party for two residents, (Resident #202 and #207) in a review of 20 residents. The facility census was 49. Review of the facility policy, Baseline Care Plans, revised March 2022, showed the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; -The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: -The stated goals and objectives of the resident; -A summary of the resident's medication and dietary instructions; -Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; -Any updated information based on the details of the comprehensive care plan, as necessary; -Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #202's face sheet showed the following: -admitted to the facility on [DATE]; -The resident was his/her own responsible party; -Diagnoses included acute and chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body that can be all at once or come on over time), chronic combined systolic and diastolic heart failure (a condition where the ventricles of the heart are unable to contract and relax properly and fails to push adequate blood into circulation), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (occurs when your breathing is interrupted during sleep, sometimes for longer than 10 seconds). Review of the resident's progress notes, dated 10/18/24 at 2:34 P.M., showed the following: -The resident arrived by private transportation; -Prior to admission he/she lived at home with family; -Arrived by wheelchair; -Alert and oriented to person, place, time and situation; -Speech was clear and he/she was able to understand and was understood; -Used continuous positive airway pressure (CPAP) (a machine to help with sleep apnea); -Continent of bladder; -Gait is unsteady. Review of the resident's medical record showed a baseline care plan was started on 10/18/24 with no signature of the resident and no signature of staff completing the baseline care plan. No documentation to show the baseline care plan was offered to the resident or that the resident had refused the offering. During an interview on 10/24/24 at 3:00 P.M., the resident said he/she did not have his/her baseline care plan explained to the resident and he/she had not received a copy of the baseline care plan. The resident's spouse was present during the interview and said he/she also had not had the baseline care plan explained to him/her and had not received a copy of the baseline care plan. 3. Review of Resident #207's face sheet showed the following: -admitted to the facility on [DATE]; -The resident was his/her own responsible party; -Diagnoses included wedge compression fracture of T9-T10 vertebra (a break in the thoracic spine that occurs when the vertebrae collapse under pressure), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of the resident's progress notes, dated 10/18/24 at 4:56 P.M., showed the following: -Resident arrived by private transportation; -Prior to admission the resident lived alone; -Adequate vision; -Alert and oriented to person, place and time; -Communicated verbally, speech is clear, is able to understand and be understood when speaking; -Continent of bladder; -Skin issue on front left shoulder; -Uses wheelchair and assist of one staff with gait belt and walker. Review of the resident's medical record showed a baseline care plan started on 10/18/24 with no signature of the resident and no signature of staff completing the baseline care plan. No documentation to show the baseline care plan was offered to the resident or that the resident had refused the offering. During an interview on 10/25/24 at 9:00 A.M., the resident said he/she did not have his/her baseline care plan explained to him/her and he/she had not received a copy of the baseline care plan. During an interview on 10/31/24 at 8:55 A.M., Licensed Practical Nurse (LPN) S said the following: -He/She was not sure who specifically was responsible for initiating the baseline care plan, but there is a baseline care plan tab that the admitting nurse starts; -The Minimum Data Set (MDS) coordinator finishes the baseline care plan; -The baseline care plan should be signed by anyone that works on it; -A copy of the baseline care plan should be given to the resident during the care plan meeting or anytime the resident requests it. During an interview on 10/25/24 at 9:11 A.M., Registered Nurse (RN) A said the following: -Baseline care plans are started at the time of the resident's admission; -The baseline care plan should be signed by the staff member completing it; -The resident received a copy of the baseline care plan when they discharge, but he/she was unaware if they received one on admission. During an interview on 10/31/24 at 3:30 P.M., the MDS Coordinator said the following: -The admitting nurse was responsible for starting and completing the baseline care plan; -After the baseline care plan was completed, the resident should sign it, the staff should sign it and a copy should be given to the resident or resident representative; -In the past, she had done the baseline care plan, but it was a challenge to complete them within 48 hours if the resident admitted on off hours or on the weekend, which was the reason the admitting nurse was doing them. During email communication on 10/31/24 at 2:22 P.M., the Assistant Director of Nursing (ADON) said the following: -The nurse that does the admission initiates the baseline care plan; -Different departments complete each section of the baseline care plan; -The resident should be given a copy of the baseline care plan once it was completed; -The baseline care plan should be signed by the people that complete it; -The only reason a resident would not be given a copy of their baseline care plan would be if they could not process the information; -A power of attorney should be given a copy of the baseline care plan; -She started the baseline care plan for Resident #202 and completed the sections she was responsible for; -She did not sign the baseline care plan for Resident #202. During an interview on 10/25/24 at 12:50 P.M., the Director of Nursing (DON) said the following: -The baseline care plan is started by the admitting nurse and the MDS Coordinator finishes the baseline care plan within 48 hours; -She would expect the nurse completing the baseline care plan to sign the care plan when completed; -She would expect the resident to be offered a copy of their baseline care plan and if they do not want one it should be documented that they were offered and refused. 42592

Based on record review, staff and resident interview, and policy review, the facility failed to ensure seven residents (Resident (R) 3, R207, R27, R31, R22, R39, R52, and R40) of 24 sampled residents remained free of accidents/hazards and received adequate supervision to prevent accidents. The facility failed to ensure coffee that was accessible to residents and served to residents was within a safe temperature range. On [DATE], R3 spilled coffee on her lap resulting in blisters on both sides of her inner thigh, and on [DATE], R40 spilled coffee on his lap. The Director of Nursing (DON) failed to ensure R207, R27, R31, R22, R39 and R52, who had falls, lacked adequate supervision, a comprehensive fall investigation after each fall, and remained free from injury. Findings include: 1. The policy titled Safety of Hot Liquids revised ,d+[DATE] revealed resident will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury .Resident who prefer hot beverages with meals will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in care plan .maintain a hot liquid serving temperature of not more than 180-degree Fahrenheit; staff supervision or assistance with hot beverages. Review of R3's Progress Notes dated [DATE], located in the Electronic Medical Record (EMR) under the Progress Notes tab, During peri care, popped blisters were noted to inside of both thighs near her groin. Resident states she had spilled hot coffee on her lap recently and the areas were from that and uncomfortable. Dressing placed for protection to stop further rubbing from brief and thighs. Review of the Investigation dated [DATE], provided by the DON revealed, R3 in dining room at breakfast and spilled her coffee in her lap, dried and assisted back to room to change pants. Blisters noted to inside bilateral groins by aide when changing resident. Aide immediately called charge nurse to come to the room. Charge nurse notified myself. [sic] Fluid filled blisters intact, covered with dry dressing to protect. When asking the resident what happened, states that she spilt her coffee in her lap. Instructed charge nurse to notify Medical Director and POA (Power of Attorney). Resident was legally blind, will assist as needed at meals. Review of R3's Admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted on [DATE] with diagnoses including venous insufficiency (peripheral), legal blindness, and hearing loss. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident was cognitively intact. The MDS revealed the resident was feeling more tired or having little energy, had no behaviors and required limited assistance with transfers, dressing and eating. During an interview with the DON, on [DATE] at 3:42 PM, she stated the unsigned investigation was completed by her on the morning of the event at approximately 10:00 AM. She stated she did not have an official form to complete the investigation. She stated she would not typically report something like this to the state agency but stated that she should have reported it. She confirmed the investigation was incomplete. DON stated R3 had spilled the coffee on herself during breakfast on [DATE]. The DON stated she had been told by the charge nurse (RN1) about the incident when she came to work on [DATE]. She stated R3 required assistance with meals and set up. She stated the Medical Director had been notified but the notification had not been documented. She stated any type of skin issue should be documented on a skin sheet and the Assistant DON (ADON) should follow up. The DON confirmed there was no statement from the charge nurse or the Certified Nurse Aide (CNA) who was working at the time. She stated there were no other burns from coffee in the facility. The DON stated there should have been a skin assessment completed by the nurse, after R3's burns were identified, weekly, and when there is something newly identified on the skin. During an observation with R3, on [DATE] at 5:30 PM, inner thighs noted to not have any signs of 2nd or 3rd degree burns to inner thighs from recent hot coffee spilling into her lap. During an interview with CNA/Certified Medication Technician (CMT), on [DATE] at 5:31 PM, she stated she did remember hearing about R3 spilling her coffee, when her shift started. She stated she had a CMT that day and remembered giving her Tylenol for pain. She stated that staff knew the coffee was hot, and stated often staff would put ice in R3's coffee because it was so hot. The CNA/CMT stated that most of the other residents on the third floor did not need ice added to their coffee because they were alert and oriented. During an observation of R3, [DATE] at 7:22 AM, R3 was holding her empty cup approximately 12 above the table in her right hand. She was holding the cup with her thumb and forefinger. She had her middle finger holding the cup and her fourth and fifth finger bent under the handle. Her hand was shaking back and forth. She placed the cup back on the table at 7:25 AM. During an observation and interview with the R3 on [DATE] at 7:28 AM, R3 took the cup of coffee, which was visibly steaming, up to her mouth and took a drink of coffee. She stated the coffee was real hot but I'll probably try it. During an interview with R14 on [DATE] at 7:32 AM, she stated the other day she took a drink and thought that's hot, I think I burned my throat. During an interview on [DATE] at 7:37 AM Dietary Aide (DA) 1 completed a temperature check on the coffee which revealed the coffee was 164 degrees. He stated that if a resident ate in their room, they would have a lid on their coffee cup, otherwise lids were not provided. He stated he remembered R3 getting burned but stated he had not received any education about hot coffee or a different way to serve it to the residents. During an interview with Registered Nurse (RN) 1 on [DATE] at 7:46 AM, he stated at first when R3 spilled her coffee, they did not know it was coffee. He stated the CNA told him that there were red areas on her thigh, and he instructed CNA1 to put A&D[vitamin A and vitamin D] ointment (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin, and minor skin irritations such as diaper rash) on the red area. He stated at 10:00 AM on the same day, CNA1 informed him there were blisters on R3's thighs and he used skin prep. He stated he did contact the Medical Director and the Medical Director ordered treatment. RN1 stated he did not document that he contacted the Medical Director, or the orders provided by the Medical Director. He stated the Medical Director told him to use skin prep. During an interview with CNA1, [DATE] at 8:23 AM, she stated she saw the resident going down the hall with her pants partially down. She stated R3 told her she had spilled coffee on herself and needed help. CNA1 stated while helping R3 she saw a red area on both of her inner thighs with more redness on her left thigh. She stated she notified RN1, and he told her to put A&D ointment on it. During an interview with the DON on [DATE] at 8:02 AM, the DON stated she would have a weekly high-risk meeting with the leadership team. She stated they would talk about each resident and had discussed that R3 had a skin irritation. She stated they were aware to watch the area. She stated usually the MDS Coordinator (MDSC) would put a note in but this time she did not. She stated there had been no training completed after the event. During an interview with RN1 on [DATE] at 11:44 AM, he stated he knew the blisters had not ruptured on the day the blisters were identified but assumed they ruptured the next day, based on the progress note. During an interview with the Medical Director, on [DATE] at 10:21 AM, she stated she did not remember whether the facility contacted her about R3's burn. She stated she would have told the facility to remove the resident's clothes, immediately clean the area, and put ice on the area to cool the skin. She stated nursing should have called her and documented that they had called her. She stated after staff observed R3's blisters she should have been notified again to order skin prep. The Medical Director stated that if she had known the blisters had ruptured, she would have ordered an antibiotic to avoid a secondary infection. During an interview with the dietary supervisor (DS), on [DATE] at 10:01 AM, she stated they do not keep a log of coffee temperatures and do not have a policy for coffee temperatures. She stated they have always been told the temperature should be not greater than 180 degrees for coffee. During an interview with CNA2 and CMT2, on [DATE] at 10:00 AM, they stated both had received training related to serving coffee to residents and providing supervision when residents are drinking coffee, prior to working their shift on the morning of [DATE]. During observations on [DATE] at 7:00 AM, Dining Room observation for breakfast of six residents found sitting at table getting served by dietary aid (DA2). All six had coffee cups with handles, and no lids at their table. During an interview with DA2, on [DATE] during the observations at 7:00 AM, DA2 stated there were no issues with spills of hot coffee and she's been there for a year and no special preparations when serving hot coffee except for sugar and creamers are added per the resident request. DA2 further revealed lids or ice is not used for hot coffee. DA2 revealed that lids are used for residents on mechanical diets. DA2 explained that this is determined based on diet cards marked as such. Observation on [DATE] at 7:15 AM, R40 was at the dining table suddenly shouted out in pain when his hot beverage spilled over into his lap and cup fell to the floor. DA2 went over to R40 and patted his lap with napkins. She then went down the hall to find the nurse on duty to report the incident to the nurse on duty, Licensed practical nurse (LPN1). DA2 then returned to R40 and began to dry the resident's pants. Observation on [DATE] at 7:25 AM, LPN1 and DON came to the dining room and took R40 back to his room to assess for any injuries from hot coffee spill. During an interview and observation on [DATE] at 7:40 AM, Surveyor requested coffee temperature check which was done per DA2 revealed coffee temperature of 167.2 F (Fahrenheit). During an interview on [DATE] at 8:00 AM, the DON confirmed there were no signs of burns to R40's skin. During an interview on [DATE] at 8:15 AM, confirmed that there were no signs of burns, and the physician was notified of the incident. R40 was changed and returned to the dining table. 2. Review of facility policy titled Investigating and Reporting Accidents and Incidents dated [DATE] reads in part Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of facility policy titled Fall Risk Reduction dated [DATE] reads in part Fall logs and fall reports will be brought to Resident-At-Risk Meeting each week and reviewed by the team to do a root-cause analysis and implement additional interventions as appropriate. Review of facility policy titled Assessing Falls and Their Causes: reads in part Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to the resident specific evidence including medical history, known functional impairments, etc. 3. Review of R1's Admission Record located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on with diagnoses that included dementia, pathological fracture, age related osteoporosis, and muscle weakness. Review of the R1's Annual MDS with an ARD [DATE] located in the EMR under the MDS tab revealed the resident had BIMS score of two of 15 indicating the resident had severely impaired cognition. The resident required limited assistance with walking with one-person physical assistance and used a walker for mobility. The MDS documented the resident sustained falls during the assessment period. Review of the resident's Quarterly MDS with an ARD of [DATE] located in the EMR MDS tab revealed the resident's BIMS score was now 00 out of 15 indicating severely impaired cognition. The resident now required supervision to limited assistance with one-person physical assistance with ADLs and used a walker for mobility. The resident sustained falls during the assessment period. Review of R1's Nursing Notes located in the resident's EMR Progress Notes tab revealed the resident sustained falls on the following days [DATE], [DATE], [DATE] (with injuries), [DATE] (with injury), and [DATE] (fell twice with injuries) Review of the facility's undated investigation completed by the DON documents the resident was found on the floor on [DATE] and [DATE]. The resident was assessed to have a hematoma on the forehead; neuro checks and vital signs were completed within normal limits. The resident was assisted up again with two persons assist and use of a gait belt. The facility MD and resident's responsible party were notified. The investigation documents the resident attempted to get up several times unassisted. The investigation failed to identify risk factors as to the cause of the resident's falls or a root cause analysis. 4. Review of R22's Admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, neuro cognitive impairment with Lewy bodies adjustment disorder, fall history, visual hallucinations, encephalopathy, and muscle weakness. Review of the resident's Quarterly MDS with an ARD [DATE] located in the resident's EMR under the MDS tab revealed the resident's BIMS score was 00 out 15 indicated the resident's cognition was severely impaired; the resident was dependent on staff for all activities of daily living (ADLs); incontinent of bladder and bowel; and falls during the assessment period. Review of R22's Nursing Notes located in the resident's EMR under the Progress Notes tab revealed the resident sustained falls on the following days: [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE] (possible injuries); and [DATE] (injuries). Review of the facility's investigation dated [DATE] completed by the DON revealed the resident was observed to stand up and start walking down the hall to his room before staff could reach him, the resident lost his balance and fell on his right side striking his head. The resident sustained a small bleeding area behind his right ear. The resident was sent to the ER for evaluation. The resident's responsible party and MD were notified. The resident later returned to the facility with the diagnosis of three rib fractures. The facility's investigation lacked witness statements and a root cause analysis of this fall. The facility did not produce investigations of the previous falls. 5. Review of R27's Admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, diabetes mellitus type II, chronic kidney disease (CKD) stage III, diabetic retinopathy, and fall history. Review of the resident's Admission MDS with an ARD of [DATE] located in the resident's EMR under the MDS tab revealed the resident had a BIMS score of four out of 15 indicated the resident has severe cognition impairment. The resident required extensive assistance with two-person physical assistance for ADLs. The resident utilized a wheelchair for mobility and triggered for falls prior to admission to the facility. Review of R27's Significant Change MDS with an ARD [DATE] located in the resident's EMR under the MDS tab revealed the resident had sustained one non injury fall since admission to the facility. Review of the resident's Nursing Notes located in the resident's EMR under the Progress Notes tab revealed the resident sustained falls on the following days [DATE], [DATE], [DATE], and [DATE]. Review of the R27's facility's investigation dated [DATE] completed by the DON revealed the DON had received a call from the charge nurse informing her of the resident's fall. The investigation indicated the resident was alert. The resident required assistance with her ADLs and was unable to get up without assistance. The resident had a full range of motion of all extremities. The resident was noted to have redness to the right side of her forehead. An ice pack was applied to the area. The resident was assisted to stand up with two-person assist and use of the gait belt. The resident's power of attorney (POA) and facility MD were notified. The investigation lacked witness statements and a root cause analysis of the fall. The facility did not provide investigations into the other falls. 6. Review of R31's Admission Record located in the resident's EMR under Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, protein calorie malnutrition fall history past right femur fracture and recent fall resulting in hip fracture with hospitalization . Review of the resident's Significant Change MDS with an ARD date [DATE] located in the resident's EMR under the MDS tab revealed the resident had BIMS score of eight out of 15 indicating the resident had cognition impairment. The resident required extensive assistance with one-person for her ADLs. The resident sustained a non-injury fall during the assessment period. Review of the resident's Quarterly MDS with an ARD date of [DATE] located in the resident's EMR under the MDS tab revealed the resident had sustained two or more non-injury falls during the assessment period. Review of R31's Nursing Notes located in the resident's EMR under the Progress Notes tab revealed the resident sustained falls on the following dates [DATE] (sustained fractured hip); [DATE] (sustained head hematoma); [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE] (sustained hip fracture). Review of the facility's investigation dated [DATE] completed by the DON revealed the resident was found on the floor by her bed. When the nurse assessed the resident, she discovered the resident had an abnormal range of motion examination and complained of pain. The facility MD and the resident's responsible party were notified. The resident was admitted to the hospital for fractured hip. The investigation lacked a root cause analysis of the resident's fall. The DON did not provide investigations of the resident's previous falls. 7. Review R39's Admission Record located in the resident's EMR under Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage III, fall history, and muscle weakness Review of the resident's Significant Change MDS with an ARD of [DATE] located in the resident's EMR under MDS tab revealed the resident had a BIMS score of six out of 15 indicating severe cognition impairment. The resident required one-person physical assistance with toileting. There were no falls during the assessment period. Review of the resident's Quarterly MDS with an ARD of [DATE] located in the resident's EMR under MDS tab revealed the resident now had a BIMS score of two out 15 indicating the resident had severe cognition impairment and the resident sustained no falls during the assessment period. Review of R 39's Nursing Notes located in the resident's EMR under Progress Notes tab revealed the resident sustained falls on the following days [DATE] (possible injury), [DATE], [DATE], and [DATE]. Review of the facility's investigation dated [DATE] completed by the DON revealed she had received a call from the facility regarding the resident fall on [DATE]. The documented the resident was found on the floor when the staff heard the resident fall. The DON documented that she examined the resident herself and observed the resident had medium size hematoma on the back of her head to which an ice pack was applied. She further documented the resident ambulates with a rotator walker. The DON documented the resident had no changes in the baseline mental status. The investigation lacked any witness statements and root cause analysis of the fall. The DON did not provide any investigation of the other falls. 8. Review of R52's Admission Record located in the resident's EMR under Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, malignant neoplasm of the prostate, chronic kidney disease stage III, fall history and lack of coordination. Review of the resident's Admission MDS with an ARD of [DATE] located in the resident's EMR under MDS tab revealed the resident had a BIMS score of eight out of 15 indicating resident had impaired cognition. The resident required limited to extensive assistance with one-person physical assist with ADLs. The resident had an indwelling foley catheter. The resident had one injurious fall prior to admission to the facility. Review of R52's Nursing Notes located in the resident's EMR under the Progress Notes tab revealed note dated [DATE] documenting the resident was admitted to the facility following a fall at home that resulted in a hip fracture requiring surgical repair. Additional review of the resident's nursing notes revealed a note dated [DATE] documenting the resident was transferring the bathroom with one-person assist and use of gait the resident lost his balance and fell . Resident stated his legs became weak and would not work. The resident was assessed to have normal ROM and no injuries. Later that day the resident was noted to have swelling to have swelling in the leg area. An x-ray was ordered which identified the resident had a fracture of distal femur. The MD was notified, and the resident was admitted to the hospital. Review of the facility's investigation dated [DATE] completed by the DON and submitted to the State regulatory office revealed the details of the resident's fall, the findings of the facility-x-ray report; notification of the resident's responsible party and the MD; copy of the resident's care plan (which was not revised with new interventions) and copy of the incident report. The incident report lacked witness statements. The DON's investigation also did not include a root cause analysis to prevent future falls. 9. Review of R207's Admission Record, located in the EMR under the Profile tab, revealed R207 was admitted on [DATE] with diagnoses including Parkinson's Disease, age-related osteoporosis, and dementia. R207 expired while in the facility on [DATE]. Review of R207's admission Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating the resident was cognitively intact. The MDS revealed the resident did not have any mood or behavior concerns. She required limited assistance with transfers, dressing and toileting, and supervision with other activities of daily living (ADL). Further review of the MDS indicated the resident had not had any previous falls. Review of R207's Care Plan located in the Care Plan tab, revised [DATE], revealed there was no care plan for falls. The fall's Care Plan was created on [DATE], during the survey and 22 days, after R207 died . Review of the Follow-up Investigation Report provided to the Missouri Department of Health and Senior Services, dated [DATE], revealed Resident had a witnessed fall. While assisting resident with transfer from wheelchair to toilet, resident stood, aide instructed resident to stand still while she moved her wheelchair, resident continued to self-transfer and fell , hitting her head and landing on her right side complains of right hip pain. The Corrective Action Taken was Resident reminded that assistance is needed when transferring. Review of the Radiology Results Report located under the Results tab, dated [DATE], revealed, RT (right) hip with Pelvis. Fall, pain ,d+[DATE] in RT hip . Impressions: Acute fracture. During an interview with DON, on [DATE] at 10:40 AM., she confirmed the resident had a fall which caused a hip fracture on [DATE]. DON stated she knew the CNA had tried to get R207 on the toilet and when moving her wheelchair out of the way R207 fell . DON stated she had not completed a thorough investigation and had not interviewed the CNA that was involved. DON stated R207 started Hospice on [DATE] and died on [DATE]. The DON stated that we have a weekly Resident at Risk meeting where we discuss residents who have had falls. She stated they had discussed R207, and everyone knew they needed to watch her. 10. An interview with the Director of Nursing (DON) on [DATE] at 3:45 PM revealed the DON was responsible for conducting investigation of all facility accidents and incidents. The floor nurse is responsible for completing the incident report, notification of the appropriate parties and documenting the electronic nurse's progress. The DON stated she was hired two years ago by the Administrator. The DON stated she was aware there was an increasing problem with resident falls. The DON stated according to a record review there were 27 resident related falls in the month of [DATE]. The DON stated that falls are addressed in the morning standup meetings, Risk Management Meetings, huddle meetings that are held on Mondays, Wednesdays, and Fridays, Safety Committee meetings, and Quality Assurance Performance Improvement (QAPI) meetings which are held quarterly. DON was unable to provide any documentation that falls were addressed in any of these meetings. During the interview, the DON provided an attendance sheet titled Meeting for Falls, Wounds, Trans/Reposition dated [DATE] at 2:00 PM. The DON stated this was a training session that addressed the issue of resident falls and preventions. DON was asked to provide a copy of the agenda for the training session; however, DON was unable to provide a copy of the agenda. In the continued interview on [DATE] at 3:45 PM the DON provided another packet identified as Fall Packet with a date of [DATE], the packet included the following forms neurological assessment flow sheet; fall intervention plan; falls; a policy titled Assessing Falls and Their Causes.' The DON stated a copy of the packet was given to staff members and instructed them to read the packet and sign the attendance sheet. The DON admitted there was no monitoring system in place to ensure the staff was following the training. The DON was asked if she had used the new packet for fall investigations that occurred after the [DATE] training and she replied that she did not use it. The DON stated she does use the document titled Fall Tracker which documents the residents' location, date/time, and risk factors of the residents' falls. She stated the document is completed every time a fall occurs. The document is presented in the facility's quarterly QAPI committee meeting. A review of the tracker log with the DON revealed the log was not consistently completed. The DON was unable to provide documentation this was present in the QAPI meetings. During an interview on [DATE] at 4:00 PM the Assistant Director of Nursing (ADON) stated the document titled Fall Packet was additional training that was conducted [DATE]. ADON stated any accidents/incidents occurring after there should be the documents in the packet completed. The facility was unable to provide an attendance sheet for the [DATE] training. The ADON was unable to verify if any of the forms were completed. In an interview on [DATE] at 4:53 PM with the DON, she stated when conducting an investigation into the fall incident she looks to see if the resident sustained any type of injury that would require the resident to be sent to the ER. The DON was unable to explain a root cause analysis. The DON confirmed she had not used the Fall Packet on any recent falls. The DON also confirmed the facility had a camera monitoring system and did not use it routinely in her investigations. The DON also confirmed the facility does not have a system in place to investigate the fall incidents despite all the policies and procedures presented during the survey. During an interview with the Administrator and the DON on [DATE] at 11:40 AM, the Administrator and DON stated they knew they were responsible for the management of the facility and were responsible for ensuring residents were safe and their needs were met. The Administrator and the DON stated they were aware that falls had gotten worse and there had been little improvement based on their lack of follow-up.

Based on record review, observation and staff interview, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: Review of the Facility Assessment updated 11/2021 for 2022, revealed, Quality Assurance overall has been delegated as a top oversight priority of our new DON (Director of Nursing). The Q1/A (Quality Improvement/Assurance) process, its' administration and report to the QA Committee and Administrator about progress, problem areas and trouble shooting [sic] will be an outgrowth of weekly UR/High Risk meetings, Monthly QA review and quarterly meetings. PCC OL/A Module has enabled better monthly tracking of Q/A measured data. The Administrator and DON failed to ensure coffee was not accessible to residents and was served to residents within a safe temperature. Specifically, R3 spilled coffee on her lap on 05/18/23 which caused blisters on both sides of her inner thigh and on 06/07/23 R40 spilled coffee on his lap. [Refer to F689] The DON failed to ensure R207, R27, R31, R22, R39 and R52, who had falls, had adequate supervision, a comprehensive fall investigation after each fall and remained free from injury. The Administrator and DON failed to ensure R207, R1, R31, R52 did not sustain an injury due to a lack of supervision. [Refer to F689] The Director of Nursing (DON) failed to consistently ensure weekly skin assessments were complete for resident (Resident (R) 3), specifically skin assessments after blisters were identified on 05/18/23, which increased the likelihood of R3 developing a significant skin issue. [Refer to F684] The Administrator and DON failed to ensure the current Activities Director was a qualified activities professional who was licensed or registered by the state. [Refer to F680] During an interview with the Administrator and the Director of Nursing (DON) on 06/09/23 at 11:40 AM, the Administrator and DON stated they knew they were responsible for the management of the facility and were responsible for ensuring residents were safe and their needs were met. The DON stated she stated she knew she was responsible for obtaining training and understanding all her job responsibilities. Both the DON and Administrator stated they would start a Performance Improvement Plan (PIP) but then it would slack and they would not complete the action steps they have identified or monitor their progress. Both agreed there were multiple concerns related to resident care throughout the facility. The Administrator and the DON stated they were aware that falls had gotten worse and there had been little improvement based on their lack of follow-up. The Administrator and the DON stated they were not aware the Activities Director needed to be certified in order to manage an activities program in the facility.

Based on interview and record review, the facility failed to ensure the Facility Assessment was maintained accurately. Specifically, the Facility Assessment had not been reviewed/revised annually and did not accurately reflect the current resident population. Findings include: Review of a facility policy titled, Facility Assessment, revised October 2018, revealed, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. This policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes . c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with . (4) cognitive or behavioral impairments. This policy further revealed, The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. The administrator. The policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. resident census data from the previous l2 months; b. resident capacity of the facility and its occupancy rate for the past 12 months. Review of the [NAME] Senior Health Facility Assessment Summary and Priorities, provided to the survey team by the Administrator, revealed Updated 11/2021 for 2022. The Facility Assessment was originally completed in November of 2017, and has continued to evolve since that time has helped us to identify and establish areas within the organization we wish to improve upon. We have classified those improvement areas into; quality improvements, facility improvements and staffing priorities. Review of the Facility Needs Assessment, dated 11/08/17, provided to the survey team by the Administrator revealed a Facility Cover Sheet that listed the Person (names/titles) involved in completing assessment. This cover sheet failed to document the current Administrator. The remainder of the Facility Needs Assessment has facility profile, demographic, census, and resident population data from 2017. There was no recent data included. During an interview 06/09/23 at 11:35 AM, the Administrator stated the Facility Assessment was last updated November 2021. The Administrator stated the [NAME] Senior Health Facility Assessment Summary and Priorities was a summary of the facility's upcoming plans. The Administrator was unable to state why the Facility Needs Assessment only had data from 2017. The Administrator was additionally unable to state why he was not listed on the Administrator although he had been employed as the Administrator since November 2021.

Based on record review and staff interview, the facility failed to ensure the activities program was directed by a qualified activities professional. Specifically, the current Activities Director was not a qualified activities professional who was licensed or registered by the state. Findings include: Review of the Extended Survey Book provided by the Administrator on 06/08/23, revealed the current Activities Director (AD) was not licensed or certified. During an interview with the Administrator, on 06/08/23 at 4:30 PM, he stated the current AD was not certified. The Administrator stated he was not aware the current AD was not certified or needed to be certified. During an interview with the AD, on 06/09/23 at 8:20 AM, she stated she was not aware until 06/08/23 that she needed to be certified to supervise the activities problem. She stated she would discuss with the Administrator the process of getting certified. During an interview with the Administrator, on 06/09/23 at 10:30 AM, he stated he had registered the AD for a class to become a certified activities professional.

Based on interview and record review, the facility failed to complete a discharge assessment using the Minimum Data Set (MDS) process within the required timeframe for two (Resident (R) 11 and R47) discharged residents reviewed in a total sample of 24 residents. Findings include: 1. Review of R11's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. R11 was discharged on [DATE]. Review of R11's MDS tab in the EMR revealed an admission MDS, with an Assessment Reference Date (ARD) of 12/13/22. The EMR revealed no evidence that a discharge MDS assessment was encoded or transmitted after the resident was discharged on [DATE]. 2. Review of R47's undated Admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. R47 was discharged on [DATE]. Review of MDS tab in the EMR revealed an admission MDS with an ARD of 12/31/22. The EMR revealed no evidence that a discharge MDS assessment was encoded or transmitted after the resident was discharged on [DATE]. During an interview on 06/08/23 at 11:03 AM, the MDS Coordinator said she did not know how she had missed completing the MDS discharge assessments. The MDS Coordinator confirmed that both R11 and R47 should have had a MDS discharge assessment completed/transmitted. During an interview on 06/09/23 at 11:35 AM, the Administrator said the facility did not have a MDS policy and that the facility followed the RAI (Resident Assessment Instrument) manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2019, revealed, Discharge Assessment-Return Not Anticipated - Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days; Must be completed within 14 days after the discharge date ; Must be submitted within 14 days after the MDS completion date.

Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one (Resident (R) 32) of one resident reviewed for hospice in a total sample of 24 residents. Findings include: Review of R32's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses including Protein Calorie Malnutrition. Review of R32's Order Summary Report, located in the EMR under the Orders tab, revealed the following order, dated 04/07/23: Pro [NAME] hospice to begin 4/6/2023. Review of R32's EMR revealed no evidence that a significant change MDS was completed in response to the resident being admitted to hospice services. During an interview on 06/08/23 at 12:56 PM, the MDS coordinator (MDSC) verified R32 was admitted to hospice services and a significant change MDS should have been completed in response. The MDSC confirmed no significant change MDS was completed for R32.

Based on observation, interview, and record review the facility failed to ensure staff utilized a gait belt during transfer of one sampled resident (Resident #1), who had a history of [REDACTED]. Staff failed to implement and modify interventions, as necessary, in accordance with current standards of practice for two residents (Resident #5 & #6), who were at high risk for falls and had a history of [REDACTED]. The facility's census was 49. 1. Review of the Certified Nurse Aide (CNA) Manual Revised Edition 2001 showed gait belts are required for all residents when performing transfers. Gait belts are placed around the resident's waist and provide the nurse assistant with a handle to hold onto for those residents who require assistance during transfers, ambulation or repositioning in the chair. The purpose of the gait belt is to ensure optimum safety and comfort for the resident and to minimize the risk of injury to the resident and/or nurse assistant. 2. Review of the facility's Gait Belt Policy and Procedure, dated 10/11 and reviewed on 9/2/16, showed the following: -Purpose: To provide safety of residents and Nursing staff members when transferring or ambulating residents; -It is the policy of the facility that all resident care direct care employees own his/her own gait belt. The gait belt must be labeled with the name of the employee to whom it belongs. The belt is to be brought to work daily as a part of the uniform; -Gait belts will be carried at all times when on duty. Gait belts will be used when transferring or ambulating residents that require the assistance of a CNA (Certified Nurse Aide)/CMT (Certified Medication Technician)/Nurse to ambulate or transfer. 3. Review of the facility's Fall Protocol, dated as revised April 2007, showed the following: -As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling; -Based on the initial assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling; -The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk; -Staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.; -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation; -If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention has resolved; -If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. 4. Review of Resident #1's Face Sheet showed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. -Admit to skilled level of care for pubic fracture and multiple rib fractures on the right side; -Physical and occupational therapy to evaluate and treat; -Care rails (rail at the head of bed) for repositioning. Review of the resident's Fall Risk Evaluation, dated 8/3/16, showed the resident at high risk for falls. Review of the resident's Preliminary Plan of Care, dated 8/3/16, showed the resident was at risk for falls based on fall risk screening related to age, recent admission and history of falls and balance. Review of the resident's CNA Daily Care Plan, dated 8/3/16, showed the following: -Used a wheelchair; -The resident needed help with toileting and transfers; -Transfers with a gait belt and assist of two staff. Review of the resident's progress note, dated 8/9/16, showed the following: -The resident complains of right hip pain; -Impression: Right pubic rami (pelvic) fracture of the superior and inferior pubic rami due to fall (prior to admission to the facility). Continue physical and occupational therapy. Right-sided rib fractures. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 8/10/16, showed the following: -Cognitively intact for daily decision making; -Required extensive assist for bed mobility, transfer, walk in room, locomotion on & off the unit, dressing, eating, toilet use, personal hygiene, and bathing; -The resident was not steady and was only able to stabilize with staff assistance with moving from seated to standing, walking, turning around, moving on and off the toilet, and surface-to-surface transfers; -Had functional limitation in range of motion of upper and lower extremity on one side; -Used a walker and wheelchair for mobility; -Continent of bowel and bladder; -Received as needed medication for pain; -Had a fall in the last month prior to admission; -Had a fracture related to a fall in the six months prior to admission; -Received physical and occupational therapy. Review of the resident's Nursing Flow Sheet Report, dated 8/15/16 at 4:28 P.M., showed the resident needed maximum assist with bed mobility and assist times one with transfers and ADL's (activities of daily living). Review of the resident's care plan, dated 8/16/16, showed the following: -Problem: I require extensive assist with my ADL's. I have a fracture. Approaches: I use bed canes for positioning and transfers. Assume unhurried manner and allow ample time for tasks; -Problem: I am at risk for possible falls related to my decreased gait and balance. Approaches: I need staff assistance with all transfers, ambulation, toileting, and ADL care. I have periods of confusion, but am able to tell you what I need help with. Review of the resident's Nursing Flow Sheet Report, dated 8/16/16 at 7:33 P.M., showed the resident required assist times one for ADL's and transfers. Review of the resident's Nursing Flow Sheet Report, dated 8/17/16 at 6:08 A.M., showed the following: -At 2:45 A.M., the resident used a call light for one assist with transfer to bedside commode (BSC). The resident transferred and pivoted well with walker and one assist. Assisted the resident to pull down undergarment, while the nurse turned his/her head to look at the bed to see if it was wet, the nurse heard the BSC move and saw the resident go down and land on his/her left side of the body. The resident complained of some discomfort on the left buttocks. The resident said he/she could stand. Assist times two with transfer to BSC, resident was able to stand on bilateral lower extremities while the resident was sitting on the BSC. The resident said, I have some pain shooting down my leg. The resident showed the nurse and pointed from left buttocks to left knee. The resident was able to move and bend knee and move left leg. Assist times two to bed, gave the resident two Norco (narcotic analgesic) per order for pain and repositioned; -At 3:10 A.M., call to the resident's physician, awaited call back. Checked on the resident again, the resident said he/she had discomfort to lower left rib area, noted no swelling or discoloration to the area at the time; -At 3:45 A.M., called the physician again and explained about facility phone and left facility number and also cell phone number; -At 4:30 A.M., called the resident's physician again and left message that would like a return call as soon as possible due to a fall; -At 5:00 A.M., called the medical director's exchange; -At 5:10 A.M., the medical director returned call, explained the situation and new orders were received to get x-rays of left ribs, left hip, and left knee due to pain. Called the mobile x-ray company with STAT (immediate) orders for x-rays; -At 6:10 A.M., mobile x-ray arrived. Review of the resident's x-ray report, dated 8/17/16, showed the following: -Ribs: Normal left rib series; -Hip Unilateral with Pelvis: There is a fracture involving the left femoral neck (hip/thigh bone) with mild displacement The joint shows no dislocation. Review of the resident's physician's orders [REDACTED].M., showed to send the resident to the emergency room for evaluation due to fall. Review of the resident's Nursing Flow Sheet Report, dated 8/17/16 at 9:45 A.M., showed the following: -Physician called and results of x-ray given. At 7:50 A.M., orders were received to sent to hospital. Ambulance was called. The resident transferred times four to the stretcher and left the building at 8:20 A.M. Review of the resident's medical record, showed the following: -The resident was readmitted to the facility on [DATE]; -The resident had a left displaced femoral neck fracture. During a telephone interview on 9/1/16 at 4:20 P.M., Licensed Practical Nurse (LPN) A, said the following: -He/she was transferring the resident from his/her bed to the BSC that was located beside the resident's bed; -The resident stood and walked to the BSC, LPN A turned his/her head to look at the resident's bed to see if it was wet, when he/she heard the BSC move and the resident yelled as he/she was falling onto his/her left side; -He/she did not have a gait belt on the resident because the resident's gait had been really good and he/she just didn't think the resident needed it; -He/She was supposed to go by the care plan and the CNA care card for resident care. During an interview on 9/1/16 at 4:30 P.M., the Rehab Director said the following: -The resident was stand by assist on 8/16/16; -She would have expected staff to use a gait belt on the resident. During an interview on 9/1/16 at 4:00 P.M., the Director of Nursing (DON) said if a resident is an extensive assist with transfers, she would expect staff to always use a gait belt and two staff members. 5. Review of Resident #5's POS showed the following: -The resident was admitted to the facility on [DATE]; -[DIAGNOSES REDACTED].), major depressive disorder (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of transient ischemic attack (TIA; a transient episode of neurological dysfunction caused by ischemia), history of falling, aphasia (a language disorder that affects a person's ability to communicate) following CVA; -Cane rails (small rails attached to bed frame near the head of the bed) up times two for repositioning; -Up ad lib (up as tolerated); -Norvasc (antihypertensive) 5 milligram (mg) once daily; -Toprol XL (beta-blocker) 25 mg once daily; -Xarelto (blood thinner) 20 mg every evening for 70 days; -Plavix (blood thinner) 75 mg once daily; -Prozac (antidepressant) 20 mg once daily; -Exelon patch (used to treat dementia) 9.5 mg/24 hours one patch daily, remove old patch daily; -Speech, occupational, and physical therapy to evaluate and treat. Review of the resident's fall risk evaluation, dated 8/1/16, showed the resident scored 16 (total score of ten or above represents high risk). Review of the resident's preliminary plan of care, dated 8/1/16, showed the following: -Transfer assist times two staff; -The resident uses a wheelchair; -The resident was at risk for falls based on screening related to age, recent admission, history of falls, mental status, and balance. The approaches checked included: Provide orientation/re-orientation to new home as needed. Evaluate fall risk weekly times four weeks. Assist in meeting toileting needs. Review of the resident's Certified Nurse Assistant (CNA) Daily Care Plan, dated 8/1/16, showed the following: -Transfers: Gait belt times two; -Written at the bottom, undated, showed bed and chair alarms on. Do not leave unattended in the room in his/her wheelchair. Review of the resident's Nursing Flow Sheet Report, dated 8/5/16 at 12:25 A.M., showed the following: -The resident is on incident follow up related to finding the resident on the floor in his/her room on 8/4/16 at 5:30 P.M. The nurse was called to the resident's room by a CNA, where the resident was found sitting on the floor in front of his/her wheelchair. The resident's leg was caught in the left wheelchair pedal, the pedal had to be removed to free the resident's ankle. The resident had redness noted on the anterior (front) side of his/her ankle and he/she winced when the area was palpated (examined by touch). The resident was able to move all other extremities, he/she was unable to explain what he/she was doing to cause him/her to be on the floor. The resident did not know if he/she hit his/her head. Director of Nursing (DON) and resident's physician notified. New orders for chair alarm, therapy looking into getting a flat call light and a lower wheelchair, bed in low position, call light within reach, bed alarm on, and door open. Will continue to monitor. Review of the resident's written care plan, dated 8/4/16 and located in the care plan book, showed the following: -I fell on [DATE]; -Goal: I will not fall for 30 days; -Approaches: Please make sure my chair and bed alarms are on. Please do not leave me unattended in my room if I am in my wheelchair. Make sure I have my call light within reach. I will have a flat call light to replace the push button model. Make sure my bed is in low position. Review of the resident's admission MDS, dated [DATE], showed the following: -Daily decision making was independent; -Required extensive assist with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing; -The resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position and when moving surface-to-surface (transfer between bed and chair or wheelchair); -Had functional limitation in range of motion in upper and lower extremity on both sides; -Used a wheelchair for mobility; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Had fallen in the last month prior to admission; -Had fallen in the last two to six months prior to admission; -Had fallen once since admission (8/1/16); -Had received an antidepressant and anticoagulant; -Had received speech, occupational, and physical therapy. Review of the resident's care plan, dated 8/20/16, showed the following: -Potential for falls related to impaired mobility, impaired balance, weakness, psychotropic medication use and history of falls; -Goal: I will not have injury related to fall through next review; -Approaches: Ensure my call light is within reach at all times and answer in a timely manner. Reorient me to my surroundings as needed. Ensure my wheelchair is within reach at all times. Floors free from spills and clutter. Establish a routine in care so I know what to expect. Offer me frequent reminders and cues. Provide adequate glare free lighting. Will wear proper fitting shoes that are supportive with non skid soles for ambulation. Instruct to stand and gain balance before beginning ambulation. Offer toileting and repositioning if restlessness is noted. When I am not wearing shoes please put on non skid footwear. Attempt to anticipate my needs. Physical and Occupational therapy evaluation and treat as ordered. I require assist times one with bed mobility, transfer, dressing, eating, toileting, hygiene, and bathing. I use bed rails for positioning and transfer. I have a chair alarm due to some impaired safety awareness. Review of the resident's Nursing Flow Sheet Report, dated 8/21/16 at 6:00 P.M., showed the following: -The resident had a very good day until 4:00 P.M. The DON was making rounds and saw the resident transfer self from wheelchair to bed and the resident slid to the mat on the floor from the side of the bed. No injuries noted or reported. The resident did not hit his/her head or had no bruising/injury. The resident did not attempt to use call light that was in reach. Education and review of call light safety reviewed with the resident stating understanding. Fall incident and follow up report started. Physician and family notified. Bed alarm in place and chair alarm in place. Will continue to monitor. Further review of the resident's care plan, showed staff failed to modify or add new approaches to the resident's care plan following the fall on 8/21/16. Review of the resident's Rehab instruction record, dated 8/31/16, showed the following: Place the resident's wheelchair on the side of the bed closest to the window, so the resident can use the bed cane with his/her left hand to get in and out of bed. Use gait belt and hands on assist. (These interventions were not added to the care plan) Observation on 9/1/16 at 10:48 A.M., showed the resident in his/her private room, in his/her wheelchair on the side of the bed closest to the door (not the window). No staff were present, the resident's call light was attached to the wheelchair and an alarm was attached to the back of the resident's wheelchair. Staff failed to follow rehab instructions and the CNA care plan by placing the resident beside the door and alone in his/her room. During an interview on 9/1/16 at 12:40 P.M., Certified Nurse Assistant (CNA) C said the following: -The CNA's use the CNA daily care plan to provide care to the residents; -If a resident has fallen interventions are added to the CNA daily care plan, plus during rounds if a resident has fallen it is passed on and anything new that staff are supposed to be doing for that resident to prevent future falls is discussed. During a telephone interview on 9/15/16 at 12:19 P.M., the DON said the following: -She would have expected the written care plan, dated 8/4/16, to be followed since it pertained to an actual fall and those interventions from the written care plan should have been added to the typed care plan dated 8/20/16; -When the resident fell on [DATE], he/she was alone in his/her room; -She could not recall if the resident's chair alarm was sounding when she witnessed the fall on 8/21/16. 6. Review of Resident #6's fall risk evaluation, dated 4/18/16, showed the resident scored 19 (total of 10 or above represented high risk). Review of the resident's MDS, dated [DATE], showed the following: -Moderately impaired daily decision making (decisions poor; cues/supervision required); -Required extensive assist with bed mobility, transfer, dressing, and bathing; -Was not steady and only able to stabilize with staff assistance with moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer; -Had no functional limitations in range of motion; -Used wheelchair for mobility; -Occasionally incontinent of urine; -Continent of bowel; -Active [DIAGNOSES REDACTED]. -Had no falls since last assessment (5/12/16); -Received an antidepressant; -Did not receive any physical, occupational, or restorative therapy. Review of the resident's care plan, dated 7/21/16, showed the following: -Problem: I have the potential for injury related to fall due to impaired mobility, impaired balance, impaired cognition, history of falls and psychotropic medication use; -Goal: I will not have injury related to fall through next review; -Approaches: Physical and occupational therapy as ordered. Floors free from spills or clutter. Provide adequate, glare free lighting. Personal items within reach. Assist to wear non-skid footwear. I use a wheelchair for locomotion, it is to have my anti-rollback device installed on it. I have a wander guard device. Orient me to surroundings. Attempt to anticipate my needs. Review of the resident's nurse's notes, dated 8/3/16, showed the following: -At 4:15 A.M., CNA assisted the resident to the bathroom, another resident from across the hall put on his/her call light. The CNA went to answer the light, the CNA said he/she encouraged the resident to wait, to use his/her call light, and that he/she would be right back. While charge nurse was taking care of another resident, the CNA informed the charge nurse that the resident was on the floor. Range of motion was performed times four without complaints of pain or discomfort. The resident had a two centimeter round hematoma (localized collection of blood within the tissue) to the back of the resident's skull. Ice applied. The resident was alert and oriented times two. The resident said, I hit my head. When asked the resident what happened, he/she said, I got up and I should have waited, but I don't know what got into me, I tripped. Assisted the resident to his/her wheelchair and then took the resident to the nurse's station to observe. Review of the resident's POS, dated 8/3/16 at 4:00 P.M., showed physical therapy evaluation and treat for transfers and strengthening. Review of the resident's nurse's notes, dated 8/4/16, showed the following: -Untimed: Staff toiled the resident and put him/her in his/her recliner. The resident said the phone rang and he/she got up to answer it; he/she fell . It was an unwitnessed fall. The housekeeper heard the resident fall and let nursing know. The DON was at the facility and completed the assessment on the resident. X-ray taken of right shoulder and right arm. Started neuro checks; -Untimed: The resident has an abrasion on his/her upper arm and bruising with swelling noted. Encourage fluids, call for assist and alarms in wheelchair and bed. Will continue to monitor. Review of the resident's Nursing Flow Sheet Report, dated 8/4/16 at 10:28 P.M., showed the following: -The resident remains on incident follow up for falls, noted bruising to right upper extremity. X-ray results were negative for dislocation or fracture to right arm and right shoulder. New order for bed alarm and chair alarm. Review of the resident's Physical Therapy Evaluation, dated 8/5/16, showed the following: -Reason for Referral: Due to a fall on 8/3 and 8/4 as a result of getting up without assist resulting in bruising. Resident referral to assess the resident for deficits impacting falls; -Therapy Necessity: No skilled intervention at this time based on the resident demonstrating baseline performance of mobility. Fall risk likely due to impaired judgement. Recommend continued use of fall alarms and supervision with all mobility. Further review of the resident's care plan, showed staff failed to modify or implement new interventions to reduce the likelihood of another fall following the falls on 8/3/16 and 8/4/16. 7. During an interview on 9/1/16 at 4:00 P.M., the DON said the following: -She expects falls to be on the care plan; -She expects staff to follow interventions on the care plan and the CNA care plan to prevent future falls; -She expects care plans to be modified and new interventions to be placed on the care plans immediately following a fall. MO 3